=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952339921
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN S GEDDES III O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2006
-----------------------------------------------------
Last Update Date | 02/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10250 SE 167TH PLACE RD SUITE 4
-----------------------------------------------------
City | SUMMERFIELD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34491-8686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-693-2545
-----------------------------------------------------
Fax | 352-693-2449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1508 TEXAS CT
-----------------------------------------------------
City | TAVARES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32778-2130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-360-0306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2954
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------