Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 2308 | AR |
NPI | 1003807785 |
---|---|
Provider Name | Dr. Dale Ray Burroughs |
First Address | Hot Springs, AR 71913-6913 |
Second Address | Hot Springs, AR 71913-6913 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2005 |
Last Update Date | 03/08/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
102457722 | (05) | AR |
T20323 | (02) |