Healthcare Provider Details

I. General information

NPI: 1073308839
Provider Name (Legal Business Name): SUBAITA TAFANNUM UDDIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2025
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 SW ARCHER RD
GAINESVILLE FL
32608-1135
US

IV. Provider business mailing address

2721 TREANOR TER
WELLINGTON FL
33414-6460
US

V. Phone/Fax

Practice location:
  • Phone: 352-376-1611
  • Fax:
Mailing address:
  • Phone: 561-729-4455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6717
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: