Basic Information
| Provider Information | |||||||||
| NPI: | 1508800178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AYUSO | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315A WESTERN BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285466338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103531011 | ||||||||
| FaxNumber: | 9103534433 | ||||||||
| Practice Location | |||||||||
| Address1: | 315A WESTERN BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285466338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103531011 | ||||||||
| FaxNumber: | 9103534433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 06/23/2011 | ||||||||
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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 | 152W00000X | 1487 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 890903B | 05 | NC | MEDICAID |