Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | MD1074 | MD |
NPI | 1013070762 |
---|---|
Provider Name | Dr. Ronald Geoffrey Havelock |
First Address | Laurel, MD 20724-2040 |
Second Address | Laurel, MD 20724-2040 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/12/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2200098 | (02) | MD |