Derek Alan Black, O.D.

Primary specialty

OptometristTaxonomy code 152W00000X

License

OPT002922 Issued in GA

Practice address

1211 Bald Ridge Marina Rd
Cumming, GA 30041-8484

Phone

(470) 239-6625

Fax

(470) 239-6626

NPI assigned

Sep 20, 2013

Last updated

Oct 26, 2020By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Optometry

Education

Southern College of Optometry, 2013

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Lake Lanier Eye Care, LLCGroup PAC ID 5991019184, 2 clinicians

Practice addresses (Care Compare)

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Eagle View Eye Care, LLC

  • Optometrist
  • Oakwood, GA
  • NPI 1508495474
  Medicare reassignment NPD Authorized official
• Lake Lanier Eye Care, LLC

  • Optometrist
  • Sugar Hill, GA
  • NPI 1013312453
  Medicare reassignment Care Compare group

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1379635200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1603670400000",
    "number": "1114353232",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1211 BALD RIDGE MARINA RD",
            "city": "CUMMING",
            "state": "GA",
            "postal_code": "300418484",
            "telephone_number": "470-239-6625",
            "fax_number": "470-239-6626"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1211 BALD RIDGE MARINA RD",
            "city": "CUMMING",
            "state": "GA",
            "postal_code": "300418484",
            "telephone_number": "470-239-6625",
            "fax_number": "470-239-6626"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "9300 DeWitt Loop",
            "address_2": "Ft Belvoir Community Hospital",
            "address_purpose": "LOCATION",
            "city": "Fort Belvoir",
            "state": "VA",
            "postal_code": "220605285",
            "country_code": "US",
            "telephone_number": "571-231-1431",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BLACK",
        "first_name": "DEREK",
        "middle_name": "ALAN",
        "name_prefix": "Dr.",
        "credential": "O.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2013-09-20",
        "last_updated": "2020-10-26",
        "certification_date": "2020-10-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "GA",
            "license": "OPT002922",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Optometrist in Cumming, GA
• Providers in Cumming, GA by specialty
• Optometrist in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 26, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.