Provider Demographics
NPI:1003243502
Name:BASALY DEMETRIOS, ROMANDA (OD)
Entity Type:Individual
Prefix:
First Name:ROMANDA
Middle Name:
Last Name:BASALY DEMETRIOS
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 1:133 RUM RUNNER WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-2267
Mailing Address - Country:US
Mailing Address - Phone:404-932-2802
Mailing Address - Fax:
Practice Address - Street 1:155 FOUNTAINS WAY STE 11
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-1144
Practice Address - Country:US
Practice Address - Phone:404-932-2802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004806152W00000X
GAOPT002962152W00000X
FLOPC6053152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist