Provider Demographics
NPI:1689406621
Name:BRADY, DEREK RUSSELL (OD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:RUSSELL
Last Name:BRADY
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 1:1693 WYANDOTTE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2305
Mailing Address - Country:US
Mailing Address - Phone:937-710-5447
Mailing Address - Fax:
Practice Address - Street 1:1693 WYANDOTTE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-2305
Practice Address - Country:US
Practice Address - Phone:937-710-5447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH007325152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty