Provider Demographics
NPI:1770319352
Name:DEREK J DAKE OD PC
Entity type:Organization
Organization Name:DEREK J DAKE OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:906-322-3312
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:906-291-2017
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty