Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 0735 | NC |
NPI | 1003912452 |
---|---|
Provider Name | Joe W Middleton |
First Address | Morganton, NC 28680-0683 |
Second Address | Morganton, NC 28655-3470 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2006 |
Last Update Date | 28/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
09603 | BCBS (01) | NC |
T64854 | (02) |