=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609266352
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JORGE K. GORB, O.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2015
-----------------------------------------------------
Last Update Date | 02/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5500 THOMASVILLE RD
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32312-3814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-877-3380
-----------------------------------------------------
Fax | 850-668-3693
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4924 ARDEN FOREST WAY
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32309-2958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-668-3693
-----------------------------------------------------
Fax | 850-668-3693
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. JORGE K. GORB
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 850-877-3380
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC 1472
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------