Provider Demographics
NPI:1730113291
Name:DERY, GABRIEL (OD)
Entity Type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:
Last Name:DERY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28521 PASEO DIANA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-2905
Mailing Address - Country:US
Mailing Address - Phone:949-275-7539
Mailing Address - Fax:949-496-2034
Practice Address - Street 1:28521 PASEO DIANA
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-2905
Practice Address - Country:US
Practice Address - Phone:949-275-7539
Practice Address - Fax:949-496-2034
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5841T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT006Medicaid
CAOP5841AMedicare UPIN