Active NPI
Nathan D Dederman, OD, FAAO
- Optometrist
- Fort Leonard Wood, MO
National Provider Identifier
1174005243
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 3451
- Practice address
- 4430 Missouri Ave # 1267
Fort Leonard Wood, MO 65473-9098 - Phone
- (505) 249-9251
- NPI assigned
- Sep 5, 2018
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 3451 | TN | Primary |
Addresses
Primary practice location
4430 Missouri Ave # 1267
Fort Leonard Wood, MO 65473-9098
Mailing address
4430 Missouri Ave # 1267
Fort Leonard Wood, MO 65473-9098
Phone (573) 596-0048
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 10002 | Other | TX | STATE LICENSE |
| 3451 | Other | TN | STATE LICENSE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3451 | TN | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1536105600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1705017600000",
"number": "1174005243",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4430 MISSOURI AVE # 1267",
"city": "FORT LEONARD WOOD",
"state": "MO",
"postal_code": "654739098",
"telephone_number": "573-596-0048"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4430 MISSOURI AVE # 1267",
"city": "FORT LEONARD WOOD",
"state": "MO",
"postal_code": "654739098",
"telephone_number": "505-249-9251"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DEDERMAN",
"first_name": "NATHAN",
"middle_name": "D",
"name_prefix": "Dr.",
"credential": "OD, FAAO",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2018-09-05",
"last_updated": "2024-01-12",
"certification_date": "2023-08-29",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "TN",
"license": "3451",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "STATE LICENSE",
"identifier": "10002",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "STATE LICENSE",
"identifier": "3451",
"state": "TN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fort Leonard Wood, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 12, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.