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General NPI Number Information
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NPI Number | 1487860037
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Entity Type | Individual
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Provider Name | BRUCE JOEL WILDE O.D.
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Gender | Male
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | ROSLYN EYE CENTER 360 WILLIS AVE
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City | ROSLYN HEIGHTS
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State | NY
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Zip | 11577
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Country | US
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Telephone | 516-484-8899
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Fax | 516-484-3311
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Provider Business Mailing Address
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Address Line | 2 BAY CLUB DR 4Y
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City | BAYSIDE
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State | NY
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Zip | 11360-2917
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Country | US
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Telephone | 718-229-0211
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Fax |
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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 | T003689 1
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License Number State | NY
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