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General NPI Number Information
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NPI Number | 1518199371
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Entity Type | Organization
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Legal Business Name | WATERLOO OPHTHALMIC DISPENSING, PC
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Dates
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Enumeration Date | 08/12/2009
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Last Update Date | 08/12/2009
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Provider Practice Location Address
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Address Line | 204 MAIN STREET SHOP CTR
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City | WATERLOO
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State | NY
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Zip | 13165-1454
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Country | US
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Telephone | 315-539-1209
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Fax | 315-539-1425
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Provider Business Mailing Address
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Address Line | 204 MAIN STREET SHOP CTR
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City | WATERLOO
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State | NY
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Zip | 13165-1454
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Country | US
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Telephone | 315-539-1209
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Fax | 315-539-1425
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Authorized Official
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Title or Position | PRESIDENT/OPTICIAN
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Name | MR. DANIEL DAVID GOODMAN
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Credential | ABOC
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Telephone | 315-539-1209
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | C004107-1
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License Number State | NY
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