Provider Demographics
NPI:1891972352
Name:DARYL G. CUSTRED, O.D., L.L.C.
Entity Type:Organization
Organization Name:DARYL G. CUSTRED, O.D., L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:CUSTRED
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:205-221-3721
Mailing Address - Street 1:1499 N AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35504-8882
Mailing Address - Country:US
Mailing Address - Phone:205-221-3721
Mailing Address - Fax:205-221-2748
Practice Address - Street 1:1499 N AIRPORT RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35504-8882
Practice Address - Country:US
Practice Address - Phone:205-221-3721
Practice Address - Fax:205-221-2748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2010-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-505-TA-126152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALDN9352OtherRAILROAD MEDICARE
AL103021OtherALABAMA MEDICAID
AL510G700122Medicare PIN
AL6082280001Medicare NSC