Basic Information
| Provider Information | |||||||||
| NPI: | 1770837874 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA PEDIATRIC EYE SPECIALISTS, INC | ||||||||
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| OtherOrganizationName: | GIACOMO S GUGGINO MD PA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 VONDERBURG DR | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136811122 | ||||||||
| FaxNumber: | 8136844924 | ||||||||
| Practice Location | |||||||||
| Address1: | 3115 W SWANN AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336094617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138797711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2012 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8136811122 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207WX0110X | N | 193200000X MULTI-SPECIALTY GROUP | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 0537934-00 | 05 | FL | MEDICAID |