Provider Demographics
NPI:1114064326
Name:MAKI, NADINE BETH (OD)
Entity Type:Individual
Prefix:DR
First Name:NADINE
Middle Name:BETH
Last Name:MAKI
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 1:7737 VICTORIA COVE CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-7217
Mailing Address - Country:US
Mailing Address - Phone:239-415-1010
Mailing Address - Fax:
Practice Address - Street 1:10000 GULF CENTER DRIVE
Practice Address - Street 2:NEXT TO TARGET OPTICAL
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913
Practice Address - Country:US
Practice Address - Phone:239-415-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2925152W00000X
MN2541152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU58693Medicare UPIN