Healthcare Provider Details

I. General information

NPI: 1053331801
Provider Name (Legal Business Name): TAMPA EYE LASER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 W DR MARTIN LUTHER KING JR BLVD
TAMPA FL
33607-6386
US

IV. Provider business mailing address

2700 W DR MARTIN LUTHER KING JR BLVD
TAMPA FL
33607-6386
US

V. Phone/Fax

Practice location:
  • Phone: 813-875-2745
  • Fax:
Mailing address:
  • Phone: 813-875-2745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN B RICHARDSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 813-877-2020