Provider Demographics
NPI:1356470686
Name:MARY M. FORESMAN O.D.P.A.
Entity Type:Organization
Organization Name:MARY M. FORESMAN O.D.P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FORESMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:850-902-2468
Mailing Address - Street 1:2260 S FERDON BLVD
Mailing Address - Street 2:#173
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-8457
Mailing Address - Country:US
Mailing Address - Phone:850-902-2468
Mailing Address - Fax:
Practice Address - Street 1:7171 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-6254
Practice Address - Country:US
Practice Address - Phone:850-902-2468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP2607152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty