Basic Information
| Provider Information | |||||||||
| NPI: | 1699768887 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORMON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | DARWIN | ||||||||
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| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9031 VALLEY CREST LN | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381387829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017572020 | ||||||||
| FaxNumber: | 9017512399 | ||||||||
| Practice Location | |||||||||
| Address1: | 9031 VALLEY CREST LN | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381387829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017572020 | ||||||||
| FaxNumber: | 9017512399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2254 | TN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | MM0701614 | 01 | DEA | OTHER | 2254 | 01 | TN | OD | OTHER |