Basic Information
| Provider Information | |||||||||
| NPI: | 1598751778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOSS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 160 | ||||||||
| Address2: | |||||||||
| City: | SHIPROCK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874200160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686001 | ||||||||
| FaxNumber: | 5053686431 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 ROAD 7586 | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874134934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804214570 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 12/27/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | T03481 | MO | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2299 | OK | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1502299 | 05 | OK | MEDICAID |