1629155106 NPI number — DAVID HERBERT UPTON OD OPTOMETRIST

Table of content: DAVID HERBERT UPTON OD OPTOMETRIST (NPI 1629155106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629155106 NPI number — DAVID HERBERT UPTON OD OPTOMETRIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UPTON
Provider First Name:
DAVID
Provider Middle Name:
HERBERT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD OPTOMETRIST
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:
1629155106
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1553
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WELLS
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04090-1553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-646-5332
Provider Business Mailing Address Fax Number:
207-646-9563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1662 POST ROAD
Provider Second Line Business Practice Location Address:
ABENAKI PROFESSIONAL PARK
Provider Business Practice Location Address City Name:
WELLS
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04090-1553
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-646-5332
Provider Business Practice Location Address Fax Number:
207-646-9563
Provider Enumeration Date:
11/01/2006

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: 152W00000X , with the licence number:  499T , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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