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General NPI Number Information
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NPI Number | 1114088796
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Entity Type | Individual
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Provider Name | PETER DISALVO OD
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Gender | Male
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Dates
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Enumeration Date | 12/13/2006
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Last Update Date | 03/27/2021
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Provider Practice Location Address
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Address Line | 2320 MIDWAY DR
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City | SANTA ROSA
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State | CA
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Zip | 95405-5017
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Country | US
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Telephone | 707-526-2020
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Fax | 707-526-2032
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Provider Business Mailing Address
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Address Line | 2624 KNOLLS DR
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City | SANTA ROSA
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State | CA
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Zip | 95405-8302
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Country | US
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Telephone | 510-684-7788
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Fax | 707-526-2032
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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 | CA5653T
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License Number State | CA
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