=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891874301
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRY METSOVAS O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2097 N TUSTIN ST
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92865-3901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-637-9999
-----------------------------------------------------
Fax | 714-637-9993
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6512
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92863-6512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-637-9999
-----------------------------------------------------
Fax | 714-637-9993
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT. 10460 TPA
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------