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General NPI Number Information
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NPI Number | 1457487837
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Entity Type | Organization
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Legal Business Name | OFALLON OPTOMETRIC CLINIC
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Dates
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Enumeration Date | 02/27/2007
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Last Update Date | 04/23/2014
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Provider Practice Location Address
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Address Line | 409 S MAIN ST
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City | O FALLON
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State | MO
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Zip | 63366-2532
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Country | US
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Telephone | 636-272-3383
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Fax | 636-272-3381
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Provider Business Mailing Address
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Address Line | 409 S MAIN ST
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City | O FALLON
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State | MO
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Zip | 63366-2532
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Country | US
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Telephone | 636-272-3383
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Fax | 636-272-3381
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | MR. MARTIN M SHULMAN
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Credential | O.D.
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Telephone | 636-272-3383
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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 | T02240
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License Number State | MO
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