Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 207W00000X | Ophthalmology | | 200300335 | NORTH CAROLINA | No |
| 2 | 207W00000X | Ophthalmology | | C53104 | CALIFORNIA | No |
| 3 | 207WX0107X | Ophthalmology | Retina Specialist | C53104 | CALIFORNIA | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | P00102182 | OTHER | | RR MEDICARE INDIVIDUAL ID |
| 2 | 562043271 | OTHER | | MAMSI GROUP ID |
| 3 | 562043271 | OTHER | | AETNA HMO/PPO GROUP ID |
| 4 | 562043271 | OTHER | | MEDCOST GROUP ID |
| 5 | 26600 | OTHER | | OPTICARE INDIVIDUAL ID |
| 6 | 562043271 | OTHER | | OPTICARE GROUP ID |
| 7 | 89134EF | MEDICAID | NORTH CAROLINA | |
| 8 | 89014T8 | MEDICAID | NORTH CAROLINA | |
| 9 | 014T8 | OTHER | | BCBS GROUP ID |
| 10 | 7674444 | OTHER | | AETNA PPO INDIVIDUAL ID |
| 11 | DB4007 | OTHER | | RAILROAD MEDICARE GROUP |
| 12 | 2090301 | OTHER | | UNITED HEALTHCARE INDIVID |
| 13 | 2115757 | OTHER | | MAMSI INDIVIDUAL ID |
| 14 | 2016814 | MEDICARE ID-TYPE UNSPECIFIED | | INDIVIDUAL ID |
| 15 | C7150 | OTHER | | MEDCOST INDIVIDUAL ID |
| 16 | 562043271 | OTHER | | UNITED HEALTHCARE GROUP |
| 17 | 3201207 | OTHER | | AETNA HMO INDIVIDUAL ID |
| 18 | H44557 | MEDICARE UPIN | NORTH CAROLINA | |
| 19 | 134EF | OTHER | | BCBS INDIVIDUAL ID |
| 20 | 2333843 | MEDICARE ID-TYPE UNSPECIFIED | | MEDICARE GROUP ID |
