Provider Demographics
NPI:1366502585
Name:EVELETH, SANDRA LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:LEE
Last Name:EVELETH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8801 COLLEGE PKWY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4882
Mailing Address - Country:US
Mailing Address - Phone:239-437-2004
Mailing Address - Fax:239-437-0501
Practice Address - Street 1:8801 COLLEGE PKWY
Practice Address - Street 2:SUITE 3
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4882
Practice Address - Country:US
Practice Address - Phone:239-437-2004
Practice Address - Fax:239-437-0501
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2463152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU09483Medicare UPIN
FL38445Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
FL20360XMedicare PIN