Provider Demographics
NPI:1083674113
Name:DERRICK, PAUL W (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:W
Last Name:DERRICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22 BEACHWOOD W
Mailing Address - Street 2:
Mailing Address - City:ISLE OF PALMS
Mailing Address - State:SC
Mailing Address - Zip Code:29451-2899
Mailing Address - Country:US
Mailing Address - Phone:803-781-2212
Mailing Address - Fax:803-233-2883
Practice Address - Street 1:7229 ST ANDREWS ROAD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-0722
Practice Address - Country:US
Practice Address - Phone:803-781-2212
Practice Address - Fax:803-233-2883
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC496152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD04966Medicaid
SCD04966Medicaid