Provider Demographics
NPI:1063709491
Name:DERRY, LEXI (OD)
Entity type:Individual
Prefix:DR
First Name:LEXI
Middle Name:
Last Name:DERRY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3331
Mailing Address - Country:US
Mailing Address - Phone:217-841-4810
Mailing Address - Fax:
Practice Address - Street 1:123 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3331
Practice Address - Country:US
Practice Address - Phone:202-618-2259
Practice Address - Fax:920-261-5343
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010474152W00000X
TX855TG152W00000X
WI3659-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010474Medicaid
IL046010474Medicaid