Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FC0801X | Contact Lens Fitter | C003643-1 | NY |
NPI | 1992903322 |
---|---|
Provider Name | Mr. Ralph Robert Tisdale |
First Address | Seaford, NY 11783-2634 |
Second Address | Seaford, NY 11783-2634 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2007 |
Last Update Date | 18/02/2009 |