=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235266131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN G BORNFELD O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 02/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 622 W DUARTE RD 101
-----------------------------------------------------
City | ARCADIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91007-7606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-446-2122
-----------------------------------------------------
Fax | 626-446-0513
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 622 W DUARTE RD 101
-----------------------------------------------------
City | ARCADIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91007-7606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-446-2122
-----------------------------------------------------
Fax | 626-446-0513
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT5505
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------