=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366085888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AZAR EYE OPTICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2019
-----------------------------------------------------
Last Update Date | 10/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31519 WINTERPLACE PKWY STE 2
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21804-1894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-546-2500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31519 WINTERPLACE PKWY STE 1
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21804-1894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-546-2500
-----------------------------------------------------
Fax | 410-546-5005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | JASON M TU
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 410-546-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------