=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962674606
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAYNE GOLDEN OD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2008
-----------------------------------------------------
Last Update Date | 05/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5045 FRUITVILLE RD STE 123 GOLDEN VISION
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34232-2269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-342-9711
-----------------------------------------------------
Fax | 941-378-3011
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5045 FRUITVILLE RD STE 123 GOLDEN VISION
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34232-2269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-342-9711
-----------------------------------------------------
Fax | 941-378-3011
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIC PHYSICIAN
-----------------------------------------------------
Name | DR. WAYNE GOLDEN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 941-342-9711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | OPC2764
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------