Provider Demographics
NPI:1083613095
Name:COMMUNITY EYE CENTER PA
Entity Type:Organization
Organization Name:COMMUNITY EYE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SPADAFORA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:941-625-1325
Mailing Address - Street 1:21275 OLEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6704
Mailing Address - Country:US
Mailing Address - Phone:941-625-1325
Mailing Address - Fax:941-625-0131
Practice Address - Street 1:21275 OLEAN BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6704
Practice Address - Country:US
Practice Address - Phone:941-625-1325
Practice Address - Fax:941-625-0131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4095152W00000X, 207W00000X
FL79133332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0790681-01Medicaid
FL079068101Medicaid
FL0790681-01Medicaid
FL77809Medicare PIN