=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851471577
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL S MCAVOY OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2006
-----------------------------------------------------
Last Update Date | 05/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 QUEEN ST
-----------------------------------------------------
City | SOUTHINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06489-1915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-628-4711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 BUNKER HILL
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-693-8088
-----------------------------------------------------
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 | 1094
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------