=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346483302
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEJANDRO M TIRADO OD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2009
-----------------------------------------------------
Last Update Date | 02/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1524 3RD ST N
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-7352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-241-3162
-----------------------------------------------------
Fax | 904-249-7190
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1524 3RD ST N
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-7352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-241-3162
-----------------------------------------------------
Fax | 904-249-7190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | LESLIE MCNEIL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-241-3162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC2566
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------