Basic Information
| Provider Information | |||||||||
| NPI: | 1528032299 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA EYE CLINIC P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 BOSTON AVE | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327014706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073390303 | ||||||||
| FaxNumber: | 4073390961 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 W. MICHIGAN ST. | ||||||||
| Address2: | STE. 118 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328064465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078960324 | ||||||||
| FaxNumber: | 4078962488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 01/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | PAPPAS | ||||||||
| AuthorizedOfficialFirstName: | HARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 4078347776 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLROIDA EYE CLINIC P A | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 208488103 | 05 | FL | MEDICAID |