=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659467074
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN PAUL RAFALSKI O.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4765 COMMERCIAL DR
-----------------------------------------------------
City | NEW HARTFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13413-6211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-736-6901
-----------------------------------------------------
Fax | 315-736-6947
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 HERTHUM RD
-----------------------------------------------------
City | WHITESBORO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13492-2243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-736-4418
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV006344
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------