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General NPI Number Information
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NPI Number | 1083624878
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Entity Type | Individual
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Provider Name | IAN D. RADEN O.D.
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Gender | Male
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Dates
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Enumeration Date | 08/08/2006
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Last Update Date | 11/07/2011
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Provider Practice Location Address
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Address Line | 551 NATIONAL HEALTH CARE DR EYE CLINIC
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City | DAYTONA BEACH
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State | FL
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Zip | 32114-1495
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Country | US
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Telephone | 386-323-7500
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Fax |
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Provider Business Mailing Address
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Address Line | 713 DELANEY AVE
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City | ORLANDO
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State | FL
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Zip | 32801-3814
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Country | US
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Telephone | 407-420-7653
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 06362T
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC3380
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License Number State | FL
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