Provider Demographics
NPI:1013976224
Name:DERBER, JEANNE RUTH (OD)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:RUTH
Last Name:DERBER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:R
Other - Last Name:DERBER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:9240 EXPLORER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-5004
Mailing Address - Country:US
Mailing Address - Phone:719-574-7000
Mailing Address - Fax:719-597-1712
Practice Address - Street 1:9240 EXPLORER DR STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-5004
Practice Address - Country:US
Practice Address - Phone:719-574-7000
Practice Address - Fax:719-597-1712
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1161152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08116105Medicaid
CO08116105Medicaid
COCF4513Medicare PIN