Basic Information
Provider Information | |||||||||
NPI: | 1295722908 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTS | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | PARRISH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PARRISH | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 215 1ST ST N | ||||||||
Address2: |   | ||||||||
City: | WINTER HAVEN | ||||||||
State: | FL | ||||||||
PostalCode: | 338814537 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8632998908 | ||||||||
FaxNumber: | 8632991061 | ||||||||
Practice Location | |||||||||
Address1: | 4337 S FLORIDA AVE | ||||||||
Address2: |   | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 338131654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8636192700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2005 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC3376 | FL | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 620502000 | 05 | FL |   | MEDICAID |