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General NPI Number Information
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NPI Number | 1639297898
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Entity Type | Organization
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Legal Business Name | MIDTOWN OPTOMETRY INC.
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Dates
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Enumeration Date | 03/27/2007
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Last Update Date | 11/11/2024
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Provider Practice Location Address
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Address Line | 2321 W MARCH LN STE A
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City | STOCKTON
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State | CA
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Zip | 95207-5265
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Country | US
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Telephone | 209-986-1880
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Fax | 209-957-8077
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Provider Business Mailing Address
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Address Line | 2321 W MARCH LN STE A
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City | STOCKTON
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State | CA
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Zip | 95207-5265
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Country | US
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Telephone | 209-986-1880
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Fax | 209-957-8077
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | DERRON TIMOTHY LEE
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Credential | OD
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Telephone | 209-986-1880
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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 | 12388T
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License Number State | CA
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