MEDICARE: OPTIMART, INC.

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	156FX1800X	Optician	OE391	FL

General Provider Information

NPI Number	:	1124235049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMART, INC.

Provider Business Mailing Address
First Line	:	4399 35TH ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33714-3717
Country	:	US
Telephone Number	:	727-812-3020
Fax Number	:	727-525-4835

Provider Business Practice Location Address
First Line	:	10041A US HIGHWAY 19
Second Line	:
City	:	PORT RICHEY
State	:	FL
Zip	:	34668-3742
Country	:	US
Telephone Number	:	727-868-0780
Fax Number	:	727-868-0819

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	GREGORY LOUIS MATHIS
Credential	:
Telephone Number	:	727-812-3020

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	08/22/2020

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Directions to “OPTIMART, INC. ” Practice Location

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