Healthcare Provider Details

I. General information

NPI: 1114072360
Provider Name (Legal Business Name): OCULOPLASTIC AND ORBITAL CONSULTANTS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 PGA BLVD STE 101
PALM BEACH GARDENS FL
33410
US

IV. Provider business mailing address

4060 PGA BLVD STE 101
PALM BEACH GARDENS FL
33410-6570
US

V. Phone/Fax

Practice location:
  • Phone: 561-845-6500
  • Fax: 561-845-6300
Mailing address:
  • Phone: 561-845-6500
  • Fax: 561-845-6300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY RIDGLEY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 561-845-6500