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General NPI Number Information
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NPI Number | 1649359522
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Entity Type | Individual
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Provider Name | WIBERT CHARLES LUSK O.D.
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Gender | Male
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Dates
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Enumeration Date | 11/03/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 5024 STATE HIGHWAY 23 WALMART VISON CENTER
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City | ONEONTA
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State | NY
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Zip | 13820
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Country | US
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Telephone | 607-433-4776
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Fax | 607-433-4695
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Provider Business Mailing Address
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Address Line | 4 LAKEVIEW DR N
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City | COOPERSTOWN
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State | NY
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Zip | 13326-3001
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Country | US
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Telephone | 607-547-8253
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Fax | 607-547-8253
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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 | 002556-1
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License Number State | NY
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