Basic Information
Provider Information | |||||||||
NPI: | 1447693551 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PAUL W DERRICK, OD PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8096 RIVERS AVE STE A | ||||||||
Address2: |   | ||||||||
City: | NORTH CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294069243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8438182020 | ||||||||
FaxNumber: | 8438182379 | ||||||||
Practice Location | |||||||||
Address1: | 8096 RIVERS AVE STE A | ||||||||
Address2: |   | ||||||||
City: | NORTH CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294069243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8438182020 | ||||||||
FaxNumber: | 8438182379 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2013 | ||||||||
LastUpdateDate: | 04/09/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DERRICK | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 8438182020 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | OD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 496 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | D04966 | 05 | SC |   | MEDICAID |