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General NPI Number Information
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NPI Number | 1487667168
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Entity Type | Organization
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Legal Business Name | BANGOR MALL EYE ASSOCIATION
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Dates
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Enumeration Date | 08/14/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 663 STILLWATER AVE
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City | BANGOR
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State | ME
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Zip | 04401-3642
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Country | US
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Telephone | 207-262-7192
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Fax |
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Provider Business Mailing Address
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Address Line | 663 STILLWATER AVE
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City | BANGOR
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State | ME
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Zip | 04401-3642
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Country | US
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Telephone | 207-262-7192
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. JOHN JOSEPH GIARDINA
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Credential | D.O.
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Telephone | 207-262-7192
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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 | OPT805
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License Number State | ME
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