Healthcare Provider Details

I. General information

NPI: 1154631174
Provider Name (Legal Business Name): TAMPA BAY OPTICAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 N HABANA AVE STE 204
TAMPA FL
33614-7146
US

IV. Provider business mailing address

4710 N HABANA AVE STE 204
TAMPA FL
33614-7146
US

V. Phone/Fax

Practice location:
  • Phone: 813-877-2400
  • Fax: 813-877-2402
Mailing address:
  • Phone: 813-877-2400
  • Fax: 813-877-2402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. ROGELIO BERDEAL JR.
Title or Position: PRESIDENT
Credential: BS OD
Phone: 813-877-2400