Healthcare Provider Details

I. General information

NPI: 1689921389
Provider Name (Legal Business Name): FLORIDA OPHTHALMIC AFFILIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 SHORELINE DRIVE SUITE 104
GULF BREEZE FL
32561-4766
US

IV. Provider business mailing address

348 MIRACLE STRIP PKWY SW SUITE 38
FORT WALTON BEACH FL
32548-5200
US

V. Phone/Fax

Practice location:
  • Phone: 855-989-2020
  • Fax: 855-290-5952
Mailing address:
  • Phone: 855-989-2020
  • Fax: 855-989-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME85614
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberME85614
License Number StateFL

VIII. Authorized Official

Name: DAVID MICHAEL MILLS
Title or Position: OWNER
Credential: MD
Phone: 855-989-2020