=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083013106
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY A DOBRODZIEJ O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2014
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 MOUNTAIN LEDGE
-----------------------------------------------------
City | WILTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12831-1993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-450-1080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 MOUNTAIN LEDGE
-----------------------------------------------------
City | WILTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12831-1993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | TUV008144
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Optometrist
-----------------------------------------------------
License Number | TUV008144
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152WV0400X
-----------------------------------------------------
Taxonomy Name | Vision Therapy Optometrist
-----------------------------------------------------
License Number | TUV008144
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV008144
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------