Healthcare Provider Details

I. General information

NPI: 1699768689
Provider Name (Legal Business Name): ROBERT LOWELL PHILLIPS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date: 03/27/2006
Reactivation Date: 04/03/2006

III. Provider practice location address

534 S 5TH ST
MACCLENNY FL
32063-2602
US

IV. Provider business mailing address

PO BOX 886
MACCLENNY FL
32063-0886
US

V. Phone/Fax

Practice location:
  • Phone: 904-259-6797
  • Fax: 904-259-5230
Mailing address:
  • Phone: 904-259-6797
  • Fax: 904-387-0969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOB233
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC930
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: