=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316059926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERARD H HUBBELL OD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 11/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 924 S FLORIDA AVE
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33803-1116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-688-6197
-----------------------------------------------------
Fax | 863-688-7508
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 924 S FLORIDA AVE
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33803-1116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-688-6197
-----------------------------------------------------
Fax | 863-688-7508
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. LAURA ALVAREZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 863-688-6197
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC1386
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------