Provider Demographics
NPI:1134100373
Name:FALLIN, HERBERT K III (OD)
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:K
Last Name:FALLIN
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 51
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238-2966
Mailing Address - Country:US
Mailing Address - Phone:941-923-4111
Mailing Address - Fax:941-926-2981
Practice Address - Street 1:8201 S TAMIAMI TRL
Practice Address - Street 2:SUITE 51
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238-2966
Practice Address - Country:US
Practice Address - Phone:941-923-4111
Practice Address - Fax:941-926-2981
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3228152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U72743Medicare UPIN
E4225Medicare ID - Type Unspecified