MEDICARE: COUZENS STAM DOMINGO PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPC 3453	FL

General Provider Information

NPI Number	:	1003955568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUZENS STAM DOMINGO PA

Provider Business Mailing Address
First Line	:	905 BEACH BLVD
Second Line	:	SUITE B
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-4303
Country	:	US
Telephone Number	:	904-246-4831
Fax Number	:	904-249-5876

Provider Business Practice Location Address
First Line	:	905 BEACH BLVD
Second Line	:	SUITE B
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-4303
Country	:	US
Telephone Number	:	904-246-4831
Fax Number	:	904-249-5876

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRYAN ANDREW STAM
Credential	:	O.D.
Telephone Number	:	904-246-4831

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	11/16/2007

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Directions to “COUZENS STAM DOMINGO PA ” Practice Location

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