MEDICARE: TAMPA BAY OPTOMETRIC GROUP 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

General Provider Information

NPI Number	:	1073670584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAMPA BAY OPTOMETRIC GROUP PA

Provider Business Mailing Address
First Line	:	PO BOX 40510
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33743-0510
Country	:	US
Telephone Number	:	727-361-0431
Fax Number	:	727-344-7952

Provider Business Practice Location Address
First Line	:	912 S MISSOURI AVE
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33756-4298
Country	:	US
Telephone Number	:	727-443-7642
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF ADMINISTRATION
Name	:	MR. GREGORY ENGEL
Credential	:
Telephone Number	:	727-361-0431

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	11/06/2009

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