1114106366 NPI number — ADINA S. GOULD OD PA

Table of content: (NPI 1114106366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114106366 NPI number — ADINA S. GOULD OD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADINA S. GOULD OD PA
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:
SOUTH FLORIDA OPTOMETRY
Provider Other Organization Name Type Code:
5
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:
1114106366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6535 ALLISON RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI BEACH
Provider Business Mailing Address State Name:
FLORIDA
Provider Business Mailing Address Postal Code:
33141
Provider Business Mailing Address Country Code:
UM
Provider Business Mailing Address Telephone Number:
786-586-9404
Provider Business Mailing Address Fax Number:
305-695-0662

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4308 ALTON RD STE 910
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33140-4560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-586-9404
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOULD
Authorized Official First Name:
ADINA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
786-586-9404

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC3743 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 620880100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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