Provider Demographics
NPI:1316202401
Name:DAKA, DEDRIX BENJAMIN (OD)
Entity Type:Individual
Prefix:DR
First Name:DEDRIX
Middle Name:BENJAMIN
Last Name:DAKA
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 1:700 8TH AVE W
Mailing Address - Street 2:STE 101
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-4737
Mailing Address - Country:US
Mailing Address - Phone:941-776-4008
Mailing Address - Fax:941-845-4963
Practice Address - Street 1:122 N BREVARD AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-4404
Practice Address - Country:US
Practice Address - Phone:863-491-7585
Practice Address - Fax:863-491-7588
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4785152W00000X
VA0618002165152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013849400Medicaid
FLH04587OtherMEDICARE PTAN