Healthcare Provider Details

I. General information

NPI: 1134104763
Provider Name (Legal Business Name): DAVID SEMON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 475 BOX 1
FPO AP
96350
US

IV. Provider business mailing address

PSC 475 BOX 1
FPO AP
96350
US

V. Phone/Fax

Practice location:
  • Phone: 81468165371
  • Fax:
Mailing address:
  • Phone: 81468165371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03430
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: