=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235672858
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNATIONAL EYE FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2016
-----------------------------------------------------
Last Update Date | 11/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4000 OLD COURT RD SUITE 204
-----------------------------------------------------
City | PIKESVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21208-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-653-2400
-----------------------------------------------------
Fax | 602-535-3165
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1135 REGINA DR
-----------------------------------------------------
City | HALETHORPE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21227-2342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-770-9300
-----------------------------------------------------
Fax | 602-535-3165
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/PRESIDENT
-----------------------------------------------------
Name | DR. SELVIN GNANAKKAN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 602-770-9300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WS0006X
-----------------------------------------------------
Taxonomy Name | Sports Vision Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------