=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306297726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMELIA ISLAND DOCTORS OF OPTOMETRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2016
-----------------------------------------------------
Last Update Date | 06/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1523 SADLER RD
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-4467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-647-4224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1523 SADLER RD
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-4467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-647-4224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GERALD SUNKIN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 330-338-9067
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC5182
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------