Provider Demographics
NPI:1407956071
Name:COLE, REAVES C (OD)
Entity Type:Individual
Prefix:DR
First Name:REAVES
Middle Name:C
Last Name:COLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 SW BAYA DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-4240
Mailing Address - Country:US
Mailing Address - Phone:386-754-6616
Mailing Address - Fax:386-754-6615
Practice Address - Street 1:621 SW BAYA DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-4240
Practice Address - Country:US
Practice Address - Phone:386-754-6616
Practice Address - Fax:386-754-6615
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3577152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620883500Medicaid
FLU2109ZMedicare ID - Type Unspecified
FL620883500Medicaid