Basic Information
Provider Information | |||||||||
NPI: | 1275841389 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EYE SPECIALISTS OF MID FLORIDA PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 407 AVENUE K SE | ||||||||
Address2: |   | ||||||||
City: | WINTER HAVEN | ||||||||
State: | FL | ||||||||
PostalCode: | 338804126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8632943504 | ||||||||
FaxNumber: | 8632948305 | ||||||||
Practice Location | |||||||||
Address1: | 2025 E EDGEWOOD DR | ||||||||
Address2: |   | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 338033601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8636654515 | ||||||||
FaxNumber: | 8636654516 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2010 | ||||||||
LastUpdateDate: | 02/27/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WELCH | ||||||||
AuthorizedOfficialFirstName: | DANIEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8632943504 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME32357 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 0585110007 | 01 |   | DMERC | OTHER |