Provider Demographics
NPI:1003508748
Name:SMALL, TAMMY DELIGAR (LDO)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:DELIGAR
Last Name:SMALL
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2819 BEGONIA RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-2301
Mailing Address - Country:US
Mailing Address - Phone:904-410-1410
Mailing Address - Fax:
Practice Address - Street 1:10991 SAN JOSE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-6600
Practice Address - Country:US
Practice Address - Phone:904-260-2719
Practice Address - Fax:904-260-8878
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3139156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty