Provider Demographics
NPI:1881123933
Name:MUTO, DEREK GEORGE (ODP)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:GEORGE
Last Name:MUTO
Suffix:
Gender:M
Credentials:ODP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 W BOISE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3503
Mailing Address - Country:US
Mailing Address - Phone:208-384-9194
Mailing Address - Fax:
Practice Address - Street 1:1175 W BOISE AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3503
Practice Address - Country:US
Practice Address - Phone:208-384-9194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100412152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist