=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881852556
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFF NETZEL O.D. PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2008
-----------------------------------------------------
Last Update Date | 05/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1720 S WALTON BLVD STE 2
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-7533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-271-2225
-----------------------------------------------------
Fax | 479-271-6225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1720 S WALTON BLVD STE 2
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-7533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-271-2225
-----------------------------------------------------
Fax | 479-271-6225
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPTOMERTRIST
-----------------------------------------------------
Name | DR. JEFF A NETZEL
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 479-271-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2529
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------