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General NPI Number Information
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NPI Number | 1922333186
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Entity Type | Organization
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Legal Business Name | MACULA AND DIABETIC EYE CENTER LLC
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Dates
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Enumeration Date | 10/06/2009
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Last Update Date | 03/24/2011
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Provider Practice Location Address
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Address Line | 4916 26TH ST W STE 200
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City | BRADENTON
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State | FL
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Zip | 34207-1712
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Country | US
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Telephone | 941-567-4078
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Fax | 941-896-7878
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Provider Business Mailing Address
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Address Line | 4916 26TH ST W STE 200
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City | BRADENTON
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State | FL
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Zip | 34207-1712
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Country | US
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Telephone | 941-567-4078
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Fax | 941-896-7878
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Authorized Official
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Title or Position | PRESIDENT
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Name | PETER G LIVINGSTON
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Credential | M.D.
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Telephone | 941-539-6779
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | ME102736
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License Number State | FL
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