Provider Demographics
NPI:1790876605
Name:DERODES, GREGORY J (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:DERODES
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 1:2311 HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-2634
Mailing Address - Country:US
Mailing Address - Phone:419-334-8121
Mailing Address - Fax:419-332-9351
Practice Address - Street 1:2311 HAYES AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-2634
Practice Address - Country:US
Practice Address - Phone:419-334-8121
Practice Address - Fax:419-332-9351
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4347152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4347OtherSTATE LIC
OH0883414Medicaid
U33817Medicare UPIN
OHDE0723161Medicare ID - Type Unspecified