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General NPI Number Information
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NPI Number | 1548314750
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Entity Type | Individual
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Provider Name | LIEZL R. SUTIJONO O.D.
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Gender | Female
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 05/23/2012
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Provider Practice Location Address
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Address Line | 529 HAYES ST
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City | SAN FRANCISCO
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State | CA
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Zip | 94102-4213
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Country | US
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Telephone | 415-553-6166
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Fax | 415-553-6168
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Provider Business Mailing Address
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Address Line | 6562 WHITBOURNE DR
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City | SAN JOSE
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State | CA
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Zip | 95120-4553
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Country | US
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Telephone | 650-892-4809
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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 | 007100
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 13658
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License Number State | CA
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