Provider Demographics
NPI:1528093622
Name:VISE, DAVID RICHARD (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RICHARD
Last Name:VISE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3530 ZAFARANO DR
Mailing Address - Street 2:SUITE C1
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-2617
Mailing Address - Country:US
Mailing Address - Phone:505-473-5100
Mailing Address - Fax:505-473-5104
Practice Address - Street 1:3530 ZAFARANO DR
Practice Address - Street 2:SUITE C1
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-2617
Practice Address - Country:US
Practice Address - Phone:505-473-5100
Practice Address - Fax:505-473-5104
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOP2411152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ9146Medicaid
NMJ9146Medicaid