Provider Demographics
NPI:1376774018
Name:SOUTHERN EYE SPECIALISTS PC
Entity Type:Organization
Organization Name:SOUTHERN EYE SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:FREDERIC
Authorized Official - Last Name:DANNEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-784-3937
Mailing Address - Street 1:PO BOX 8863
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36304-0863
Mailing Address - Country:US
Mailing Address - Phone:850-784-3937
Mailing Address - Fax:851-522-9829
Practice Address - Street 1:2500 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4412
Practice Address - Country:US
Practice Address - Phone:850-784-3937
Practice Address - Fax:851-522-9829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63970207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid
FLPENDINGMedicare PIN