Basic Information
Provider Information
NPI: 1033557426
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ROSENBLATT
FirstName: MYRA
MiddleName: DENNIS
NamePrefix:  
NameSuffix:  
Credential: O.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: DENNIS
OtherFirstName: MYRA
OtherMiddleName: EMILY
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 1
Mailing Information
Address1: 7 TIMBERWOOD DR
Address2: APT. 425
City: LEBANON
State: NH
PostalCode: 037664467
CountryCode: US
TelephoneNumber: 6788779769
FaxNumber:  
Practice Location
Address1: 15 E STATE ST
Address2:  
City: MONTPELIER
State: VT
PostalCode: 056023086
CountryCode: US
TelephoneNumber: 8022237723
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/07/2013
LastUpdateDate: 06/28/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X0878NHN Eye and Vision Services ProvidersOptometrist 
152W00000X030.0095851VTY Eye and Vision Services ProvidersOptometrist 

No ID Information.


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