MEDICARE: DESTIN OPHTHALMOLOGY, 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	207W00000X	Ophthalmology Physician	ME90933	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IND NPI	OTHER		1851398093

General Provider Information

NPI Number	:	1912994518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTIN OPHTHALMOLOGY, PA

Provider Business Mailing Address
First Line	:	7720 US HIGHWAY 98 W
Second Line	:	SUITE 110
City	:	DESTIN
State	:	FL
Zip	:	32550-7230
Country	:	US
Telephone Number	:	850-622-0757
Fax Number	:	850-622-1978

Provider Business Practice Location Address
First Line	:	7720 US HIGHWAY 98 W
Second Line	:	SUITE 110
City	:	DESTIN
State	:	FL
Zip	:	32550-7230
Country	:	US
Telephone Number	:	850-622-0757
Fax Number	:	850-622-1978

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PRISCILLA G FOWLER
Credential	:	MD
Telephone Number	:	850-622-0757

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	08/22/2020

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