Basic Information
| Provider Information | |||||||||
| NPI: | 1508807595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DZIADUL | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A. | ||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8081 ARCO CORPORATE DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276172042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192865237 | ||||||||
| FaxNumber: | 9192865223 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 VETERANS WAY | ||||||||
| Address2: | |||||||||
| City: | VIERA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216373788 | ||||||||
| FaxNumber: | 3216373509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 04/22/2019 | ||||||||
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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 | OPC 2258 | FL | N | Eye and Vision Services Providers | Optometrist | 152WL0500X | OPC 2258 | FL | Y | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation |
No ID Information.