Provider Demographics
NPI:1699081067
Name:NORTH FLORIDA EYE CENTER PA
Entity type:Organization
Organization Name:NORTH FLORIDA EYE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:FANOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-331-7337
Mailing Address - Street 1:410 N MAIN ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CHIEFLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32626-0866
Mailing Address - Country:US
Mailing Address - Phone:352-493-2634
Mailing Address - Fax:352-493-2517
Practice Address - Street 1:410 N MAIN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626-0866
Practice Address - Country:US
Practice Address - Phone:352-493-2634
Practice Address - Fax:352-493-2517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4437156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL49379OtherBCBS OF FL
FL257002500Medicaid
FL257002500Medicaid