Provider Demographics
NPI:1497728984
Name:MOUNT DORA OPHTHALMOLOGY ASC LLC
Entity Type:Organization
Organization Name:MOUNT DORA OPHTHALMOLOGY ASC LLC
Other - Org Name:MID FLORIDA SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD # L&C
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6187
Mailing Address - Country:US
Mailing Address - Phone:615-240-3820
Mailing Address - Fax:615-234-1720
Practice Address - Street 1:17564 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6711
Practice Address - Country:US
Practice Address - Phone:352-735-4100
Practice Address - Fax:352-735-2444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL876261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL079101600Medicaid
FL079101600Medicaid
FLF1154Medicare PIN
FL=========OtherHUMANA MILITARY HEALTHCAR
FL10C0001154Medicare Oscar/Certification