Provider Demographics
NPI:1811975931
Name:DERIN J VAN LOON OD PA
Entity type:Organization
Organization Name:DERIN J VAN LOON OD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DERIN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:VAN LOON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-727-1004
Mailing Address - Street 1:213 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1985
Mailing Address - Country:US
Mailing Address - Phone:218-727-1004
Mailing Address - Fax:218-727-1525
Practice Address - Street 1:213 W 1ST ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1985
Practice Address - Country:US
Practice Address - Phone:218-727-1004
Practice Address - Fax:218-727-1525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNDD9233OtherRAILROAD MEDICARE
MN413668300Medicaid
MN413668300Medicaid
MN5506010001Medicare NSC