Provider Demographics
NPI:1073625331
Name:SOUTHEAST EYE INSTITUTE, PA
Entity Type:Organization
Organization Name:SOUTHEAST EYE INSTITUTE, PA
Other - Org Name:EYE ASSOCIATES OF PINELLAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESSIDENT / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BAPTIST
Authorized Official - Last Name:WACHTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:727-541-4469
Mailing Address - Street 1:9375 66TH ST N
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33782-4418
Mailing Address - Country:US
Mailing Address - Phone:727-541-4469
Mailing Address - Fax:727-546-9661
Practice Address - Street 1:9375 66TH ST
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33782-4418
Practice Address - Country:US
Practice Address - Phone:727-541-4469
Practice Address - Fax:727-546-9661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2459152W00000X
207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273965800Medicaid
FL1285100001Medicare NSC
FL273965800Medicaid