=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225443062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAVISH RAMNIKLAL BHALANI O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2014
-----------------------------------------------------
Last Update Date | 06/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1871 CARL D SILVER PKWY UNIT 1113
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22401-4969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-786-8081
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 COUNTRY CT
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22554-8812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-846-2202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0618002347
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------