1689921389 NPI number — FLORIDA OPHTHALMIC AFFILIATES, PA

Table of content: (NPI 1689921389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689921389 NPI number — FLORIDA OPHTHALMIC AFFILIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA OPHTHALMIC AFFILIATES, 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:
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:
1689921389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
348 MIRACLE STRIP PKWY SW
Provider Second Line Business Mailing Address:
SUITE 38
Provider Business Mailing Address City Name:
FORT WALTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32548-5200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-989-2020
Provider Business Mailing Address Fax Number:
855-989-2020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 SHORELINE DRIVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
GULF BREEZE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32561-4766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-989-2020
Provider Business Practice Location Address Fax Number:
855-290-5952
Provider Enumeration Date:
08/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MILLS
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
855-989-2020

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  ME85614 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0122X , with the licence number: ME85614 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 006482200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 006482201 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 006482206 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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