1912994518 NPI number — DESTIN OPHTHALMOLOGY, PA

Table of content: (NPI 1912994518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912994518 NPI number — DESTIN OPHTHALMOLOGY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESTIN OPHTHALMOLOGY, 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:
1912994518
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7720 US HIGHWAY 98 W
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
DESTIN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32550-7230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-622-0757
Provider Business Mailing Address Fax Number:
850-622-1978

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7720 US HIGHWAY 98 W
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
DESTIN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32550-7230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-622-0757
Provider Business Practice Location Address Fax Number:
850-622-1978
Provider Enumeration Date:
09/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FOWLER
Authorized Official First Name:
PRISCILLA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
850-622-0757

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  ME90933 , 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: IND NPI . This is a "1851398093" identifier . This identifiers is of the category "OTHER".




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