1679764617 NPI number — EYE DOCTORS OPTICAL OUTLETS PA

Table of content: (NPI 1679764617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679764617 NPI number — EYE DOCTORS OPTICAL OUTLETS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE DOCTORS OPTICAL OUTLETS 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:
1679764617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5607 JOHNS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33634-4317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-885-3937
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4121 US HIGHWAY 98 N
Provider Second Line Business Practice Location Address:
#A-140
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33809-3818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-859-7100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COPPOLA
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-917-2337

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: 620937831 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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