=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144254939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESTIN OPHTHALMOLOGY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 03/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7700 US HIGHWAY 98 W SUITE 201
-----------------------------------------------------
City | SANTA ROSA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32459-3270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-622-0757
-----------------------------------------------------
Fax | 850-622-1978
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7700 US HIGHWAY 98 W SUITE 201
-----------------------------------------------------
City | SANTA ROSA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32459-3270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-622-0757
-----------------------------------------------------
Fax | 850-622-1978
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | MRS. PRISCILLA G. FOWLER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 850-622-0757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | ME90933
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------