=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942277678
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRWIN ROBERT DUDOW O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2006
-----------------------------------------------------
Last Update Date | 12/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8101 SUNLAND BLVD
-----------------------------------------------------
City | SUN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91352-3949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-767-2050
-----------------------------------------------------
Fax | 818-767-2056
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 366
-----------------------------------------------------
City | SUN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91353-0366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-767-2050
-----------------------------------------------------
Fax | 818-767-2056
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | OP4775TLG
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WV0400X
-----------------------------------------------------
Taxonomy Name | Vision Therapy Optometrist
-----------------------------------------------------
License Number | OP4775TLG
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OP4775TLG
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------