Healthcare Provider Details

I. General information

NPI: 1144366964
Provider Name (Legal Business Name): ROGER FREY L.D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 E FLETCHER AVE
TAMPA FL
33612-3668
US

IV. Provider business mailing address

1410 E FLETCHER AVE
TAMPA FL
33612-3668
US

V. Phone/Fax

Practice location:
  • Phone: 813-977-4801
  • Fax: 813-979-4572
Mailing address:
  • Phone: 813-977-4801
  • Fax: 813-979-4572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDO2954
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: