Provider Demographics
NPI:1043209455
Name:FIRST COAST RETINA CENTER PA
Entity Type:Organization
Organization Name:FIRST COAST RETINA CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:RAPPAPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-997-1100
Mailing Address - Street 1:8833 PERIMETER PARK BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8833 PERIMETER PARK BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1109
Practice Address - Country:US
Practice Address - Phone:904-997-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3229Medicare ID - Type Unspecified