1548893746 NPI number — MI OPTOMETRA INC

Table of content: (NPI 1548893746)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548893746 NPI number — MI OPTOMETRA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MI OPTOMETRA INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548893746
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5142 HOOK HOLLOW CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32837-4913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-251-3582
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5991 S GOLDENROD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32822-8775
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-583-9372
Provider Business Practice Location Address Fax Number:
407-377-7645
Provider Enumeration Date:
02/15/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TORRES AYALA
Authorized Official First Name:
EUGENIO
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
321-300-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 112672100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".