Basic Information
| Provider Information | |||||||||
| NPI: | 1194998591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TATUM | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHOPPELLC | ||||||||
| OtherFirstName: | TATUM | ||||||||
| OtherMiddleName: | OPTICAL | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7100 SIX FORKS RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276156156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198470187 | ||||||||
| FaxNumber: | 9196762231 | ||||||||
| Practice Location | |||||||||
| Address1: | 2351 ERWIN RD | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277054699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192820053 | ||||||||
| FaxNumber: | 9192820057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2008 | ||||||||
| LastUpdateDate: | 02/12/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | 1277 | NC | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.