1740729821 NPI number — MID FLORIDA EYE CENTER PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740729821 NPI number — MID FLORIDA EYE CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID FLORIDA EYE CENTER 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:
1740729821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17560 US HIGHWAY 441
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT DORA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32757-6711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-735-2020
Provider Business Mailing Address Fax Number:
352-735-5187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5743 WILLIAMSBURG LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILDWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34785-8129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-735-2020
Provider Business Practice Location Address Fax Number:
352-735-0479
Provider Enumeration Date:
02/22/2017

Additional Information

Authorized Official

Authorized Official Last Name:
NEAL
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
469-214-0144

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 376541500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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