=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003243502
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROMANDA BASALY DEMETRIOS O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2013
-----------------------------------------------------
Last Update Date | 07/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 FOUNTAINS WAY STE 11
-----------------------------------------------------
City | SAINT JOHNS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259-1144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-932-2802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 133 RUM RUNNER WAY
-----------------------------------------------------
City | SAINT JOHNS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259-2267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-932-2802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901004806
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT002962
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC6053
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------