Healthcare Provider Details

I. General information

NPI: 1497388722
Provider Name (Legal Business Name): EYE DOCTORS OPTICAL OUTLETS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2020
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10689 BIG BEND RD
RIVERVIEW FL
33579-7176
US

IV. Provider business mailing address

5607 JOHNS RD
TAMPA FL
33634-4499
US

V. Phone/Fax

Practice location:
  • Phone: 813-699-1980
  • Fax:
Mailing address:
  • Phone: 813-885-3937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: ANETTE ALLGOOD
Title or Position: CREDENTIALING
Credential:
Phone: 800-353-5420