Provider Demographics
NPI:1316508708
Name:PHELPS, DEREK MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:MICHAEL
Last Name:PHELPS
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1215 W RIO SALADO PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-2954
Mailing Address - Country:US
Mailing Address - Phone:480-480-2020
Mailing Address - Fax:480-612-0150
Practice Address - Street 1:1215 W RIO SALADO PKWY STE 101
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-2954
Practice Address - Country:US
Practice Address - Phone:480-480-2020
Practice Address - Fax:480-612-0150
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005485152W00000X
OHOPT.006797152W00000X
AZOPT002423152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist