Basic Information
| Provider Information | |||||||||
| NPI: | 1700048329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ASHBY | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 326 DOZIER AVE | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812122706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192760344 | ||||||||
| FaxNumber: | 7192697446 | ||||||||
| Practice Location | |||||||||
| Address1: | 326 DOZIER AVE | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812122706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192760344 | ||||||||
| FaxNumber: | 7192697446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2008 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT-2652 | CO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 87751747 | 05 | CO | MEDICAID | P00827172 | 01 | RAILROAD MEDICARE | OTHER | 1679525208 | 01 | OFFICE GROUP NPI | OTHER | 1376983924 | 01 | GROUP NPI | OTHER |