Provider Demographics
NPI:1265665079
Name:JUAN A MENJIVAR OD PA
Entity Type:Organization
Organization Name:JUAN A MENJIVAR OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MENJIVAR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:281-630-6052
Mailing Address - Street 1:1414 SE 8TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-4057
Mailing Address - Country:US
Mailing Address - Phone:281-630-6052
Mailing Address - Fax:
Practice Address - Street 1:180 S KNOWLES AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-7009
Practice Address - Country:US
Practice Address - Phone:407-629-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-26
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4351152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFD548AMedicare PIN