Provider Demographics
NPI:1285779140
Name:DARYN W DERSTINE OD PC
Entity type:Organization
Organization Name:DARYN W DERSTINE OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARYN
Authorized Official - Middle Name:W
Authorized Official - Last Name:DERSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-654-6217
Mailing Address - Street 1:12000 SE 82ND AVE
Mailing Address - Street 2:1008
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97086
Mailing Address - Country:US
Mailing Address - Phone:503-654-6217
Mailing Address - Fax:503-654-9335
Practice Address - Street 1:12000 SE 82ND AVE
Practice Address - Street 2:1008
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-7721
Practice Address - Country:US
Practice Address - Phone:503-654-6217
Practice Address - Fax:503-654-9335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2773ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR112980Medicare ID - Type UnspecifiedGROUP MEDICARE #