Provider Demographics
NPI:1386733194
Name:FEIFKE, DEREK (OD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:FEIFKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:50 MALL RD
Practice Address - Street 2:SUITE 114
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-4537
Practice Address - Country:US
Practice Address - Phone:781-229-2020
Practice Address - Fax:781-229-2025
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3624152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA732656OtherTUFTS HEALTHCARE
MA151586OtherHARVARD PILGRIM HEALTH CA
MAW15882Medicare ID - Type Unspecified