Basic Information
| Provider Information | |||||||||
| NPI: | 1588990758 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYE SPECIALISTS OF MID FLORIDA, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 407 AVENUE K SE | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338804126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632943504 | ||||||||
| FaxNumber: | 8632990096 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 A RIDGE WAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAKE WALES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636762008 | ||||||||
| FaxNumber: | 8636766638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2009 | ||||||||
| LastUpdateDate: | 03/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | WELCH | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8632943504 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EYE SPECIALISTS OF MID FLORIDA P.A. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 0585110002 | 01 | DMERC | OTHER |