Basic Information
| Provider Information | |||||||||
| NPI: | 1902956030 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TB EYE CARE PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | INNOVISION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11650 131ST ST | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337744740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274890500 | ||||||||
| FaxNumber: | 7274890508 | ||||||||
| Practice Location | |||||||||
| Address1: | 36021 US HIGHWAY 19 N | ||||||||
| Address2: | |||||||||
| City: | PALM HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346841531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277721000 | ||||||||
| FaxNumber: | 7277710770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GILLETTE | ||||||||
| AuthorizedOfficialFirstName: | THEDORE | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7274890500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.