Provider Demographics
NPI:1831397306
Name:SANDBERG, DERRI (OD)
Entity type:Individual
Prefix:DR
First Name:DERRI
Middle Name:
Last Name:SANDBERG
Suffix:
Gender:F
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 NW CARLON AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-2636
Mailing Address - Country:US
Mailing Address - Phone:541-382-3242
Mailing Address - Fax:541-317-3579
Practice Address - Street 1:901 NW CARLON AVE STE 2
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2636
Practice Address - Country:US
Practice Address - Phone:541-382-3242
Practice Address - Fax:541-317-3579
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3213ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR243164Medicaid