Healthcare Provider Details

I. General information

NPI: 1760784102
Provider Name (Legal Business Name): CARLY ELIZABETH MIGLIORINO OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARLY ELIZABETH MIGLIORINO OD

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 SUN VISTA DR
LUTZ FL
33559
US

IV. Provider business mailing address

3157 WINGLEWOOD CIR
LUTZ FL
33558-5051
US

V. Phone/Fax

Practice location:
  • Phone: 813-607-2730
  • Fax:
Mailing address:
  • Phone: 813-253-9828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4830
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC4625
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: