=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922162320
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID TIMOTHY DUVENDACK O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2006
-----------------------------------------------------
Last Update Date | 11/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4445 WOODMONT RD
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43613-3320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-346-3216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 351627
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43635-1627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-425-9273
-----------------------------------------------------
Fax | 419-423-7124
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OH5026
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------