Basic Information
Provider Information
NPI: 1366437162
EntityType: 2
ReplacementNPI:  
OrganizationName: EYE SPECIALISTS OF MID FLORIDA PA
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
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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: 407 AVENUE K SE
Address2:  
City: WINTER HAVEN
State: FL
PostalCode: 33880
CountryCode: US
TelephoneNumber: 8632943504
FaxNumber: 8632948305
Other Information
ProviderEnumerationDate: 09/19/2005
LastUpdateDate: 07/13/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: WELCH
AuthorizedOfficialFirstName: DANIEL
AuthorizedOfficialMiddleName: W
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 8632943504
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207W00000X601197FLY193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansOphthalmology 

ID Information
IDTypeStateIssuerDescription
25487630005FL MEDICAID
25487630205FL MEDICAID
25487630305FL MEDICAID
25487630405FL MEDICAID
25487630605FL MEDICAID
25487630105FL MEDICAID
25487630505FL MEDICAID


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