Provider Demographics
NPI:1538447347
Name:STORM, DEREK ALAN (O D)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:ALAN
Last Name:STORM
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6622 STONE CROSSING DR
Mailing Address - Street 2:APT. D
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-2330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6622 STONE CROSSING DR
Practice Address - Street 2:APT. D
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-2330
Practice Address - Country:US
Practice Address - Phone:217-821-8849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2868152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist