Provider Demographics
NPI:1225708282
Name:PEMBERTON, NORMAN (OD)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:
Last Name:PEMBERTON
Suffix:
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 1:8711 SW 30TH ST APT 106
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1829
Mailing Address - Country:US
Mailing Address - Phone:305-878-4534
Mailing Address - Fax:
Practice Address - Street 1:13852 SW 88TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-1304
Practice Address - Country:US
Practice Address - Phone:305-662-2990
Practice Address - Fax:888-371-2283
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC6015152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPC6015OtherSTATE LICENSE