Provider Demographics
NPI:1720073984
Name:TEDDY, SHERRIE D (ODPA)
Entity type:Individual
Prefix:DR
First Name:SHERRIE
Middle Name:D
Last Name:TEDDY
Suffix:
Gender:F
Credentials:ODPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 SEVEN SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-3623
Mailing Address - Country:US
Mailing Address - Phone:727-372-0414
Mailing Address - Fax:727-372-9313
Practice Address - Street 1:2740 SEVEN SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-3623
Practice Address - Country:US
Practice Address - Phone:727-372-0414
Practice Address - Fax:727-372-9313
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2011-10-07
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
FLOPC1797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPC1797OtherFL LICENSE
FL19293ZOtherMEDICARE PTAN
FL410031537OtherMEDICARE RR
FL117635OtherEYEMED PROVIDER NUMBER
FL19293OtherB.C. B.S. ID NUMBER
FL0482470001OtherPALMETTO GBA/ DMERC
FL19293OtherB.C. B.S. ID NUMBER
FLT84159Medicare UPIN