Provider Demographics
NPI:1528156734
Name:EXECUTIVE PARK EYE CARE, PLLC
Entity type:Organization
Organization Name:EXECUTIVE PARK EYE CARE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DERBER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:719-574-7000
Mailing Address - Street 1:9240 EXPLORER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-5004
Mailing Address - Country:US
Mailing Address - Phone:719-574-7000
Mailing Address - Fax:719-597-1712
Practice Address - Street 1:9240 EXPLORER DR STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-5004
Practice Address - Country:US
Practice Address - Phone:719-574-7000
Practice Address - Fax:719-597-1712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO27239721Medicaid
CO27239721Medicaid
CO1305460001Medicare NSC