1710394622 NPI number — FLORIDA RETINA SPECIALISTS, P.A.

Table of content: DR. ANDREW C JOHNSON DDS, MDS, CDT (NPI 1508296005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710394622 NPI number — FLORIDA RETINA SPECIALISTS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA RETINA SPECIALISTS, P.A.
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:
1710394622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
280 N SYKES CREEK PKWY STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERRITT ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32953-3491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-735-8800
Provider Business Mailing Address Fax Number:
321-735-8898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2329 MEDICO LN STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32940-8449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-735-8800
Provider Business Practice Location Address Fax Number:
321-690-2288
Provider Enumeration Date:
07/14/2014

Additional Information

Authorized Official

Authorized Official Last Name:
O'REILLY
Authorized Official First Name:
KACIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
321-735-8800

Provider Taxonomy Codes

  • Taxonomy code: 207WX0107X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 012539300 . 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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