Provider Demographics
NPI:1083859409
Name:GULF COAST OPTOMETRY, PA
Entity type:Organization
Organization Name:GULF COAST OPTOMETRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:239-896-0046
Mailing Address - Street 1:1725 W DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6507
Mailing Address - Country:US
Mailing Address - Phone:239-275-2241
Mailing Address - Fax:954-656-1049
Practice Address - Street 1:1725 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6507
Practice Address - Country:US
Practice Address - Phone:239-800-1717
Practice Address - Fax:954-656-1049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-15
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3782152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty