Healthcare Provider Details

I. General information

NPI: 1336213735
Provider Name (Legal Business Name): ERIC E MIEDEMA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MCHENRY AVENUE SUITE 77
MODESTO CA
95350-4318
US

IV. Provider business mailing address

1700 MCHENRY AVENUE SUITE 77
MODESTO CA
95350-4318
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-4626
  • Fax: 209-524-1046
Mailing address:
  • Phone: 209-524-4626
  • Fax: 209-524-1046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT9947TPA
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: