Provider Demographics
NPI:1104911098
Name:ANDREANOS JORDANOPOULOS OD INC
Entity type:Organization
Organization Name:ANDREANOS JORDANOPOULOS OD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREANOS
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDANOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:321-723-8115
Mailing Address - Street 1:1573 SOUTH WICKHAM ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3540
Mailing Address - Country:US
Mailing Address - Phone:321-723-8115
Mailing Address - Fax:321-723-7388
Practice Address - Street 1:1573 SOUTH WICKHAM ROAD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3540
Practice Address - Country:US
Practice Address - Phone:321-723-8115
Practice Address - Fax:321-723-7388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL2531152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6081OtherMEDICARE GROUP NUMBER
FL5251220001Medicare NSC
FLK6081OtherMEDICARE GROUP NUMBER
U51434Medicare UPIN