=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649368713
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL DAVID CERUTTI O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9973 MANCHESTER RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63122-1915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-961-3151
-----------------------------------------------------
Fax | 314-961-1735
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10336 TOPAZ SPRING DR
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63123-6270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-638-4123
-----------------------------------------------------
Fax | 314-961-1735
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TO2672
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------