MEDICARE: DR. IAN JAMES MIDDLETON OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5308T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144224791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IAN JAMES MIDDLETON OD

Provider Business Mailing Address
First Line	:	1559 FARMERS LN
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-7525
Country	:	US
Telephone Number	:	707-571-2020
Fax Number	:	707-540-6299

Provider Business Practice Location Address
First Line	:	1559 FARMERS LN
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-7525
Country	:	US
Telephone Number	:	707-571-2020
Fax Number	:	707-540-6299

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	07/22/2010

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