Provider Demographics
NPI:1326478652
Name:POURKESALI ENTERPRISES LLC
Entity Type:Organization
Organization Name:POURKESALI ENTERPRISES LLC
Other - Org Name:PALM COAST EYE PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:POURKESALI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:386-246-6289
Mailing Address - Street 1:391 PALM COAST PKWY SW UNIT 2
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-4766
Mailing Address - Country:US
Mailing Address - Phone:386-246-6289
Mailing Address - Fax:386-246-6389
Practice Address - Street 1:391 PALM COAST PKWY SW UNIT 2
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4766
Practice Address - Country:US
Practice Address - Phone:386-246-6289
Practice Address - Fax:386-246-6389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8658207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7327Medicare UPIN