MEDICARE: EYE DOCTORS OPTICAL OUTLETS, 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508466889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE DOCTORS OPTICAL OUTLETS, PA

Provider Business Mailing Address
First Line	:	5607 JOHNS RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33634-4499
Country	:	US
Telephone Number	:	813-885-3937
Fax Number	:

Provider Business Practice Location Address
First Line	:	2469 W US HIGHWAY 90 STE A27
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-4738
Country	:	US
Telephone Number	:	386-515-8647
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	ANETTE ALLGOOD
Credential	:
Telephone Number	:	800-353-5420

Provider Enumeration Date	:	10/27/2020
Last Update Date	:	10/27/2020

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