Healthcare Provider Details

I. General information

NPI: 1134612948
Provider Name (Legal Business Name): PATRICK JOSEPH CASSIDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 W SAMPLE RD
POMPANO BEACH FL
33064-3542
US

IV. Provider business mailing address

5 W SAMPLE RD
POMPANO BEACH FL
33064-3542
US

V. Phone/Fax

Practice location:
  • Phone: 954-782-1700
  • Fax:
Mailing address:
  • Phone: 954-782-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5019
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: