MEDICARE: OPTIMART, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician	OE386	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013124882
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMART, INC.

Provider Business Mailing Address
First Line	:	4359 35TH ST N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33714-3717
Country	:	US
Telephone Number	:	727-914-8615
Fax Number	:	727-914-8610

Provider Business Practice Location Address
First Line	:	2637 E GULF TO LAKE HWY
Second Line	:
City	:	INVERNESS
State	:	FL
Zip	:	34453-3216
Country	:	US
Telephone Number	:	352-637-5180
Fax Number	:	352-637-5181

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	GREGORY LOUIS MATHIS
Credential	:
Telephone Number	:	727-914-8615

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	07/01/2020

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Directions to “OPTIMART, INC. ” Practice Location

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