Provider Demographics
NPI:1962584474
Name:MCTYIER, DEREK (OD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MCTYIER
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 1:314 E MCLOUGHLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-3387
Mailing Address - Country:US
Mailing Address - Phone:360-694-8303
Mailing Address - Fax:360-694-9032
Practice Address - Street 1:314 E MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3387
Practice Address - Country:US
Practice Address - Phone:360-694-8303
Practice Address - Fax:360-694-9032
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0004011152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031870Medicaid
WA2031870Medicaid
WAV08786Medicare UPIN