Provider Demographics
NPI:1124780796
Name:DERDERIAN, ELORIE LILAH
Entity type:Individual
Prefix:
First Name:ELORIE
Middle Name:LILAH
Last Name:DERDERIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 S LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1433
Mailing Address - Country:US
Mailing Address - Phone:248-929-9220
Mailing Address - Fax:
Practice Address - Street 1:1236 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1433
Practice Address - Country:US
Practice Address - Phone:248-929-9220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist