Healthcare Provider Details

I. General information

NPI: 1316771207
Provider Name (Legal Business Name): RODNELL STEPHEN GONZALES BATAC OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2024
Last Update Date: 09/21/2024
Certification Date: 09/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 ERWIN RD DUMC BOX 3802
DURHAM NC
27710-4699
US

IV. Provider business mailing address

2351 ERWIN ROAD DUMC BOX 3802
DURHAM NC
27710-4113
US

V. Phone/Fax

Practice location:
  • Phone: 919-681-3937
  • Fax:
Mailing address:
  • Phone: 702-353-8183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2803
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: