Provider Demographics
NPI:1073665766
Name:OPTOMETRIC PHYSICIAN'S GROUP
Entity Type:Organization
Organization Name:OPTOMETRIC PHYSICIAN'S GROUP
Other - Org Name:OPTICS SOHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAHLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:813-643-7300
Mailing Address - Street 1:6152 DELANCEY STATION ST
Mailing Address - Street 2:STE. 101
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-4206
Mailing Address - Country:US
Mailing Address - Phone:813-643-7300
Mailing Address - Fax:813-643-2276
Practice Address - Street 1:6152 DELANCEY STATION ST
Practice Address - Street 2:STE. 101
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-4206
Practice Address - Country:US
Practice Address - Phone:813-643-7300
Practice Address - Fax:813-643-2276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2269152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19578Medicare ID - Type Unspecified
FLT12883Medicare UPIN