=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265668842
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMERALD COAST EYE CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2009
-----------------------------------------------------
Last Update Date | 11/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1714 W 23RD ST SUITE K
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-2932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-215-9101
-----------------------------------------------------
Fax | 850-215-9102
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1714 W 23RD ST SUITE K
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-2932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-215-9101
-----------------------------------------------------
Fax | 850-215-9102
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. WILLIAM PAYTON PATTERSON
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 850-832-3421
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC 4373
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------