=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093722894
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL MENEAKIS OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2006
-----------------------------------------------------
Last Update Date | 01/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 612 N PASEO DE ONATE STE C
-----------------------------------------------------
City | ESPANOLA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87532-2963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-753-7355
-----------------------------------------------------
Fax | 505-753-7533
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 612 N PASEO DE ONATE STE C
-----------------------------------------------------
City | ESPANOLA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87532-2963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-753-7355
-----------------------------------------------------
Fax | 505-753-7533
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 307
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------