Provider Demographics
NPI:1346678240
Name:JACKSONVILLE EYE CARE
Entity Type:Organization
Organization Name:JACKSONVILLE EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIFFENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:410-628-1510
Mailing Address - Street 1:3332 PAPER MILL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:MD
Mailing Address - Zip Code:21131-1419
Mailing Address - Country:US
Mailing Address - Phone:410-628-1510
Mailing Address - Fax:
Practice Address - Street 1:3332 PAPER MILL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:MD
Practice Address - Zip Code:21131-1419
Practice Address - Country:US
Practice Address - Phone:410-628-1510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-31
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1372152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU60706Medicare UPIN