1578613006 NPI number — MR. JOHN GADSBY BIRDSALL III OPHTHALMIC DISPENSER

Table of content: MR. JOHN GADSBY BIRDSALL III OPHTHALMIC DISPENSER (NPI 1578613006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578613006 NPI number — MR. JOHN GADSBY BIRDSALL III OPHTHALMIC DISPENSER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIRDSALL
Provider First Name:
JOHN
Provider Middle Name:
GADSBY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
OPHTHALMIC DISPENSER
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578613006
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 VINE ST.
Provider Second Line Business Mailing Address:
PO BOX 28
Provider Business Mailing Address City Name:
GILBERTSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-783-2222
Provider Business Mailing Address Fax Number:
607-336-1003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5811 COUNTY RT. 32
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORWICH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-336-2020
Provider Business Practice Location Address Fax Number:
607-336-1003
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  5008 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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