MEDICARE: DR. TOBY PALM O.D.

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	1327	AZ
2	152W00000X	Optometrist	2872T	OR

General Provider Information

NPI Number	:	1366430936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TOBY PALM O.D.

Provider Business Mailing Address
First Line	:	201 DAKOTA STREET
Second Line	:
City	:	SUTHERLIN
State	:	OR
Zip	:	97479-9113
Country	:	US
Telephone Number	:	541-459-4333
Fax Number	:	541-459-7512

Provider Business Practice Location Address
First Line	:	201 DAKOTA STREET
Second Line	:
City	:	SUTHERLIN
State	:	OR
Zip	:	97479-9113
Country	:	US
Telephone Number	:	541-459-4333
Fax Number	:	541-459-7512

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

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	07/17/2015

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