MEDICARE: RETINA PHYSICIANS AND SURGEONS OF TAMPA BAY, LLC

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	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1588111975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RETINA PHYSICIANS AND SURGEONS OF TAMPA BAY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 858
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34682-0858
Country	:	US
Telephone Number	:	727-789-8770
Fax Number	:	727-789-8784

Provider Business Practice Location Address
First Line	:	3280 N MCMULLEN BOOTH RD
Second Line	:	SUITE 120
City	:	CLEARWATER
State	:	FL
Zip	:	33761-2029
Country	:	US
Telephone Number	:	727-789-8770
Fax Number	:	727-789-8774

Authorized Official
Title or Position	:	OWNER
Name	:	DANA M DEUPREE
Credential	:	MD
Telephone Number	:	727-789-8770

Provider Enumeration Date	:	09/02/2016
Last Update Date	:	09/02/2016

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