Provider Demographics
NPI:1073522611
Name:BLANDFORD OPTICAL SHOP
Entity Type:Organization
Organization Name:BLANDFORD OPTICAL SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RODNEY
Authorized Official - Last Name:ROZAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-664-6123
Mailing Address - Street 1:5 SAINT VINCENT CIR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5412
Mailing Address - Country:US
Mailing Address - Phone:501-664-6123
Mailing Address - Fax:
Practice Address - Street 1:5 SAINT VINCENT CIR
Practice Address - Street 2:SUITE 101
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5412
Practice Address - Country:US
Practice Address - Phone:501-664-6123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0394250001Medicare ID - Type Unspecified