=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275655417
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICHARD A. JABLONSKI, DO PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2007
-----------------------------------------------------
Last Update Date | 01/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1425 HAND AVE SUITE A
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-1135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-673-3345
-----------------------------------------------------
Fax | 386-672-1854
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1425 HAND AVE SUITE A
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-1135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-673-3345
-----------------------------------------------------
Fax | 386-672-1854
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. RICHARD A JABLONSKI
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 386-673-3345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | OS3838
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------