=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871796201
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAY S. FOLKMAN OD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2007
-----------------------------------------------------
Last Update Date | 02/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6821 MONTGOMERY BLVD NE STE C
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-1410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-881-7440
-----------------------------------------------------
Fax | 505-837-2117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6821 MONTGOMERY BLVD NE STE C
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-1444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-881-7440
-----------------------------------------------------
Fax | 505-837-2117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. JAY S FOLKMAN
-----------------------------------------------------
Credential | O.D.P.C
-----------------------------------------------------
Telephone | 505-881-7440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OP2294
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------