Provider Demographics
NPI:1265407084
Name:CUNNINGHAM, DEREK N (OD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:N
Last Name:CUNNINGHAM
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 1:901 MOPAC EXPRESSWAY SOUTH
Mailing Address - Street 2:BUILDING 4 SUITE 350
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-5776
Mailing Address - Country:US
Mailing Address - Phone:512-347-0255
Mailing Address - Fax:512-347-0785
Practice Address - Street 1:901 MOPAC EXPRESSWAY SOUTH
Practice Address - Street 2:BUILDING 4 SUITE 350
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-5776
Practice Address - Country:US
Practice Address - Phone:512-347-0255
Practice Address - Fax:512-347-0785
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALR164TA776152W00000X
TX06300T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166400501Medicaid
TX8B6942Medicare ID - Type Unspecified
AL510-10589OtherBC-2003 MEDICAL CENTER DR, BAY MINETTE
AL510-10583OtherBC-1811 HAND AVE, BAY MINETTE
AL510-10590OtherBC-106 WEST JACKSON ST, BREWTON
ALU95870Medicare UPIN
AL510-10592OtherBC-7101 US HIGHWAY 90, DAPHNE
AL515-45645OtherBC-3290 DAUPHIN ST, SUITE 401, MOBILE
AL1265407084Medicaid
TX166400501Medicaid
AL510I410014Medicare PIN