=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134100373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HERBERT K FALLIN III OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8201 S TAMIAMI TRL SUITE 51
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34238-2966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-923-4111
-----------------------------------------------------
Fax | 941-926-2981
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8201 S TAMIAMI TRL SUITE 51
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34238-2966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-923-4111
-----------------------------------------------------
Fax | 941-926-2981
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC3228
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------