Provider Demographics
NPI:1679596837
Name:DEAPEN, JOHN DORAN (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DORAN
Last Name:DEAPEN
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 1:1106 S W S YOUNG DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-4881
Mailing Address - Country:US
Mailing Address - Phone:254-690-1000
Mailing Address - Fax:254-690-2617
Practice Address - Street 1:1106 S W S YOUNG DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-4881
Practice Address - Country:US
Practice Address - Phone:254-690-1000
Practice Address - Fax:254-690-2617
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03461T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT12965Medicare UPIN
TX5738540001Medicare NSC
TX00860HMedicare ID - Type Unspecified