Provider Demographics
NPI:1134454218
Name:ENEWOLD, TAIRA (OD)
Entity type:Individual
Prefix:
First Name:TAIRA
Middle Name:
Last Name:ENEWOLD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 KUENZLI ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1117
Mailing Address - Country:US
Mailing Address - Phone:775-329-5162
Mailing Address - Fax:775-334-4356
Practice Address - Street 1:1715 KUENZLI ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1117
Practice Address - Country:US
Practice Address - Phone:775-329-5162
Practice Address - Fax:775-334-4356
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV37415Medicare PIN