=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548473721
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GABLES VISION OPTICAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 07/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1661 SW 37TH AVE STE 100
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33145-1754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-447-0702
-----------------------------------------------------
Fax | 305-447-0504
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1661 SW 37TH AVE STE 100
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33145-1754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-447-0702
-----------------------------------------------------
Fax | 305-447-0504
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST SOLE PROPRIETOR
-----------------------------------------------------
Name | ABRAHAM AWAD
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 305-447-0702
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC2717
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------