=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972916096
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID M. GIRARDI, OD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2014
-----------------------------------------------------
Last Update Date | 06/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 824 FRANKLIN PARK DR
-----------------------------------------------------
City | EAST SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13057-1614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-446-1288
-----------------------------------------------------
Fax | 315-446-2210
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 824 FRANKLIN PARK DR
-----------------------------------------------------
City | EAST SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13057-1614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-446-1288
-----------------------------------------------------
Fax | 315-446-2210
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DAVID M GIRARDI
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 315-446-1288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV005152
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------