Healthcare Provider Details

I. General information

NPI: 1609151752
Provider Name (Legal Business Name): DAX VASILIOU O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 N WICKHAM RD
MELBOURNE FL
32940-2028
US

IV. Provider business mailing address

PO BOX 320630
COCOA BEACH FL
32932-0630
US

V. Phone/Fax

Practice location:
  • Phone: 321-751-7270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 5025
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: