MEDICARE: DR. JEFFREY K CUSTRED OD

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	OPC002268	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1669411021	OTHER	FL	MEDICARE NPI

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
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669411021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY K CUSTRED OD

Provider Business Mailing Address
First Line	:	5795 LAKE VICTORIA DR
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-4709
Country	:	US
Telephone Number	:	863-646-0219
Fax Number	:

Provider Business Practice Location Address
First Line	:	2128 JIM REDMAN PKWY
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33563-7105
Country	:	US
Telephone Number	:	813-752-3320
Fax Number	:	813-759-6595

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

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	06/02/2008

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