Provider Demographics
NPI:1447810510
Name:WARREN, DEREK LEE (OD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:LEE
Last Name:WARREN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 W THOMPSON WAY
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-6871
Mailing Address - Country:US
Mailing Address - Phone:208-241-1058
Mailing Address - Fax:
Practice Address - Street 1:9820 W LOWER BUCKEYE RD STE 101
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-1412
Practice Address - Country:US
Practice Address - Phone:623-215-0009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002351152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist