Provider Demographics
NPI:1093028631
Name:BLADE, PAMELA JISELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:JISELLE
Last Name:BLADE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9001 TABORFIELD AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836
Mailing Address - Country:US
Mailing Address - Phone:407-217-7375
Mailing Address - Fax:
Practice Address - Street 1:9001 TABORFIELD AVE.
Practice Address - Street 2:SUITE 101
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32836
Practice Address - Country:US
Practice Address - Phone:407-217-7375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-25
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist