Provider Demographics
NPI:1427436187
Name:SOUTHEASTERN RETINA SPECIALISTS, PA
Entity type:Organization
Organization Name:SOUTHEASTERN RETINA SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:DELP
Authorized Official - Suffix:
Authorized Official - Credentials:OCS
Authorized Official - Phone:904-527-3577
Mailing Address - Street 1:7740 POINT MEADOWS DR
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9179
Mailing Address - Country:US
Mailing Address - Phone:904-527-3577
Mailing Address - Fax:904-527-3514
Practice Address - Street 1:7740 POINT MEADOWS DR
Practice Address - Street 2:SUITE 3A
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9179
Practice Address - Country:US
Practice Address - Phone:904-527-3577
Practice Address - Fax:904-527-3514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0064370207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G708648Medicare PIN