Provider Demographics
NPI:1427380120
Name:3D EYEWEAR
Entity Type:Organization
Organization Name:3D EYEWEAR
Other - Org Name:3D EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMIKO
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-319-3904
Mailing Address - Street 1:4505 E HILLSBOROUGH AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-5200
Mailing Address - Country:US
Mailing Address - Phone:813-319-3904
Mailing Address - Fax:813-319-3997
Practice Address - Street 1:4505 E HILLSBOROUGH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-5200
Practice Address - Country:US
Practice Address - Phone:813-319-3904
Practice Address - Fax:813-319-3997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 152WP0200X, 152WS0006X, 156FC0800X, 156FC0801X, 156FX1202X, 156FX1800X
FLOB3204152W00000X
FLDO4826156FX1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Single Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Single Specialty
No156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic AssistantGroup - Single Specialty
No156FX1202XEye and Vision Services ProvidersTechnician/TechnologistOptometric TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL630366800Medicaid