Provider Demographics
NPI:1154739852
Name:SALOMON, KATIE M (OD)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:SALOMON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 AVENUE K SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4203
Mailing Address - Country:US
Mailing Address - Phone:863-401-4200
Mailing Address - Fax:863-220-9912
Practice Address - Street 1:570 AVENUE K SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4203
Practice Address - Country:US
Practice Address - Phone:863-401-4200
Practice Address - Fax:863-220-9912
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4961152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105924700Medicaid