MEDICARE: ESAAM EL-DEAN ISMAIL O.D.

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	152W00000X	Optometrist	OPC2529	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

General Provider Information

NPI Number	:	1588728539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ESAAM EL-DEAN ISMAIL O.D.

Provider Business Mailing Address
First Line	:	215 S GOODMAN AVE
Second Line	:
City	:	LAKE ALFRED
State	:	FL
Zip	:	33850-3003
Country	:	US
Telephone Number	:	863-297-5067
Fax Number	:	863-294-8786

Provider Business Practice Location Address
First Line	:	410 CITI CTR
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33880-3425
Country	:	US
Telephone Number	:	863-297-5067
Fax Number	:	863-297-5067

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	07/08/2007

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