Provider Demographics
NPI:1740766716
Name:DAKE, DEREK JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:JAMES
Last Name:DAKE
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 1:315 W VICTORY WAY
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:MI
Mailing Address - Zip Code:49868-1647
Mailing Address - Country:US
Mailing Address - Phone:906-322-3312
Mailing Address - Fax:
Practice Address - Street 1:504 W HARRIE ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:MI
Practice Address - Zip Code:49868-1200
Practice Address - Country:US
Practice Address - Phone:906-291-2015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005127152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist