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General NPI Number Information
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NPI Number | 1194597690
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Entity Type | Organization
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Legal Business Name | VISION SOURCE MAITLAND, LLC
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Dates
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Enumeration Date | 10/27/2023
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Last Update Date | 02/18/2025
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Provider Practice Location Address
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Address Line | 238 S ORLANDO AVE
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City | MAITLAND
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State | FL
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Zip | 32751
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Country | US
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Telephone | 407-971-1001
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Fax | 407-971-1002
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Provider Business Mailing Address
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Address Line | 238 S ORLANDO AVE
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City | MAITLAND
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State | FL
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Zip | 32751-5604
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Country | US
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Telephone | 407-971-1001
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Fax | 407-971-1002
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DAVID N FISHER
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Credential | OD
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Telephone | 407-462-3738
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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