Healthcare Provider Details

I. General information

NPI: 1306992847
Provider Name (Legal Business Name): GRACE B DORADO OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRACE B DORADO-FOSTER OD

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4890 BIG ISLAND DR STE 1
JACKSONVILLE FL
32246
US

IV. Provider business mailing address

4890 BIG ISLAND DR SUITE 1
JACKSONVILLE FL
32246
US

V. Phone/Fax

Practice location:
  • Phone: 904-379-1260
  • Fax: 904-564-2646
Mailing address:
  • Phone: 904-379-1260
  • Fax: 904-564-2646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC2509
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: