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General NPI Number Information
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NPI Number | 1366514309
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Entity Type | Individual
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Provider Name | KEYDRON DWANE DEROSA OD DOCTOR OF OPTOMET
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Gender | Male
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Dates
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Enumeration Date | 11/14/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1275 NORTH HERMITAGE ROAD WALMART VISION CENTER
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City | HERMITAGE
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State | PA
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Zip | 16148
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Country | US
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Telephone | 724-346-5950
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Fax | 724-342-6246
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Provider Business Mailing Address
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Address Line | 6599 WEST MIDDLETOWN ROAD
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City | CANFIELD
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State | OH
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Zip | 44406-9417
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Country | US
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Telephone | 330-702-8855
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Fax | 330-702-8855
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4976P
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3165T405
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License Number State | OH
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