Basic Information
| Provider Information | |||||||||
| NPI: | 1184638934 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DESIGNER EYEWEAR, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5205 NORMANDY BLVD | ||||||||
| Address2: | SUITE #3 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322054841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047817717 | ||||||||
| FaxNumber: | 9047816367 | ||||||||
| Practice Location | |||||||||
| Address1: | 5205 NORMANDY BLVD | ||||||||
| Address2: | SUITE #3 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322054841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047817717 | ||||||||
| FaxNumber: | 9047816367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 10/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | AKEL | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9047817717 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WX0102X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Occupational Vision | 152WV0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Vision Therapy | 152W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 620423600 | 05 | FL | MEDICAID |