Healthcare Provider Details

I. General information

NPI: 1750322368
Provider Name (Legal Business Name): RAYMOND AMADO HERMIDA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2229 W NEW HAVEN AVE
MELBOURNE FL
32904-3805
US

IV. Provider business mailing address

2229 W NEW HAVEN AVE
MELBOURNE FL
32904-3805
US

V. Phone/Fax

Practice location:
  • Phone: 321-726-6551
  • Fax: 321-726-0443
Mailing address:
  • Phone: 321-726-6551
  • Fax: 321-726-0443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC2898
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC2898
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberOB2475
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: