Provider Demographics
NPI:1174693410
Name:DEREK HADEN, OD PC
Entity type:Organization
Organization Name:DEREK HADEN, OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-335-5139
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:1115 SOUTH ELM STREET
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30529-0007
Mailing Address - Country:US
Mailing Address - Phone:706-335-5139
Mailing Address - Fax:706-335-6393
Practice Address - Street 1:1115 S ELM ST
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-2843
Practice Address - Country:US
Practice Address - Phone:706-335-5139
Practice Address - Fax:706-335-6393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
GA1689152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1245223890OtherNPI/ DR. ROY E. DOSS
GA00278319BMedicaid
GA00810389AMedicaid
GAGA1689OtherGA LICENSE # DR. DOSS
GA41ZCDMCMedicare PIN
GA1284520001Medicare NSC
GAGRP3421Medicare PIN
GAGA1689OtherGA LICENSE # DR. DOSS
GA00278319BMedicaid
GA41ZCDMDMedicare PIN
GA1730172289OtherDR. JON MILFORD NPI #
GAGA 1016OtherGA. LICENSE # DR. MILFORD