Provider Demographics
NPI:1871601294
Name:FATURA, DEREK FREDERICK (OD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:FREDERICK
Last Name:FATURA
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 1:6123 ALLIENE RD
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-9653
Mailing Address - Country:US
Mailing Address - Phone:231-843-6640
Mailing Address - Fax:
Practice Address - Street 1:4854 W US HIGHWAY 10
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-8703
Practice Address - Country:US
Practice Address - Phone:231-843-6553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004196152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI48638OtherDAVIS VISION ID#
MIWALM19063OtherSPECTERA USER ID#
MI213230OtherCOLE MANAGED VISION CIA#
MIU9B966Medicare UPIN
MI0P02270Medicare PIN