MEDICARE: DR. DARYL G CUSTRED O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	S-505-TA-126	AL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	0555770001	OTHER		MEDICARE NSC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	051546600	OTHER	AL	BCBS OF AL

General Provider Information

NPI Number	:	1215047097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DARYL G CUSTRED O.D.

Provider Business Mailing Address
First Line	:	1499 N AIRPORT RD
Second Line	:
City	:	JASPER
State	:	AL
Zip	:	35504-8882
Country	:	US
Telephone Number	:	205-221-3721
Fax Number	:	205-221-2748

Provider Business Practice Location Address
First Line	:	1499 N AIRPORT RD
Second Line	:
City	:	JASPER
State	:	AL
Zip	:	35504-8882
Country	:	US
Telephone Number	:	205-221-3721
Fax Number	:	205-221-2748

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	11/11/2010

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Directions to “ DR. DARYL G CUSTRED O.D.” Practice Location

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