Basic Information
Provider Information | |||||||||
NPI: | 1538525266 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TB EYECARE PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | INNOVISION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11650 131ST ST | ||||||||
Address2: |   | ||||||||
City: | LARGO | ||||||||
State: | FL | ||||||||
PostalCode: | 337744740 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7274890500 | ||||||||
FaxNumber: | 7274890508 | ||||||||
Practice Location | |||||||||
Address1: | 11650 131ST ST | ||||||||
Address2: |   | ||||||||
City: | LARGO | ||||||||
State: | FL | ||||||||
PostalCode: | 337744740 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7274890500 | ||||||||
FaxNumber: | 7274890508 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2016 | ||||||||
LastUpdateDate: | 01/11/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GILLETTE | ||||||||
AuthorizedOfficialFirstName: | THEODORE | ||||||||
AuthorizedOfficialMiddleName: | N | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7274890500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | O.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC1574 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
No ID Information.