=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912932666
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLARISSA DAWN GLOVER-DANQUE O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 07/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 275 W. 28TH STREET SUITE 1
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-7304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-782-1980
-----------------------------------------------------
Fax | 928-345-2950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 275 W. 28TH STREET SUITE 1
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-7304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-782-1980
-----------------------------------------------------
Fax | 928-345-2950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1682
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | S-A73-TA-641
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2535
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------