Basic Information
Provider Information | |||||||||
NPI: | 1912032566 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTH FLORIDA VISION SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTH FLORIDA VISION CENTERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2900 W CYPRESS CREEK RD STE 4 | ||||||||
Address2: |   | ||||||||
City: | FT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 333091715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9547265047 | ||||||||
FaxNumber: | 9547266372 | ||||||||
Practice Location | |||||||||
Address1: | 2900 W CYPRESS CREEK RD | ||||||||
Address2: | SUITE 1 | ||||||||
City: | FORT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 333091715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9549792191 | ||||||||
FaxNumber: | 9549798988 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2007 | ||||||||
LastUpdateDate: | 10/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COPPOLA | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9547265047 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | O.D. | ||||||||
NPICertificationDate: | 10/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC1910 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 621006609 | 05 | FL |   | MEDICAID |