Healthcare Provider Details

I. General information

NPI: 1215772132
Provider Name (Legal Business Name): FALLON DE VAY HENDERSON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13800 VETERANS WAY
ORLANDO FL
32827-7401
US

IV. Provider business mailing address

822 KILLARNEY CT
MERRITT ISLAND FL
32953-8065
US

V. Phone/Fax

Practice location:
  • Phone: 407-599-1404
  • Fax:
Mailing address:
  • Phone: 321-514-2340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC6523
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: