=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538444757
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CURTIS OPHTHALMOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2011
-----------------------------------------------------
Last Update Date | 03/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 MAIN ST SUITE1
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-1545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-239-5460
-----------------------------------------------------
Fax | 607-239-5465
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 MAIN ST SUITE 1
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-1545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-239-5460
-----------------------------------------------------
Fax | 607-239-5465
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | THEODORE H CURTIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 607-239-5460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 259317
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------