=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841530086
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANE PURDY O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2013
-----------------------------------------------------
Last Update Date | 09/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 N MAIN ST
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32536-3543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-683-0221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 N MAIN ST
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32536-3543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-683-0221
-----------------------------------------------------
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 | 5281
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------