=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689639528
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD BRADLEY FUSS O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2006
-----------------------------------------------------
Last Update Date | 04/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5006 SINCLAIR LN
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21206-5936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-488-6800
-----------------------------------------------------
Fax | 410-488-4270
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12615 WATERSPOUT CT
-----------------------------------------------------
City | OWINGS MILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21117-1024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-356-9291
-----------------------------------------------------
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 | TA1167
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | TA1167
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152WP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Optometrist
-----------------------------------------------------
License Number | TA1167
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152WS0006X
-----------------------------------------------------
Taxonomy Name | Sports Vision Optometrist
-----------------------------------------------------
License Number | TA1167
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------