Provider Demographics
NPI:1235825886
Name:LAI, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:LAI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 W MAITLAND ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-4739
Mailing Address - Country:US
Mailing Address - Phone:626-643-4388
Mailing Address - Fax:
Practice Address - Street 1:4605 BROCKTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0107
Practice Address - Country:US
Practice Address - Phone:951-686-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT35491-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist