=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629118351
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY C. APPOLD OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2007
-----------------------------------------------------
Last Update Date | 02/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4900 FASHION SQUARE BLVD SEARS OPTICAL
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48604-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-799-1184
-----------------------------------------------------
Fax | 989-791-1918
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2165 5TH ST
-----------------------------------------------------
City | BAY CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48708-6343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-225-1965
-----------------------------------------------------
Fax | 989-791-1918
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901003161
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------