=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437213451
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH ALAN BORTNICK O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 K SOUTH SALISBURY BLVD.
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-546-1369
-----------------------------------------------------
Fax | 410-546-5987
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7311 E RANIER DR
-----------------------------------------------------
City | PARSONSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21849-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-546-1369
-----------------------------------------------------
Fax | 410-546-5987
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TAO709
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0601000758
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------