Provider Demographics
NPI:1508049925
Name:VISIONARY OPTOMETRY INC
Entity Type:Organization
Organization Name:VISIONARY OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:R
Authorized Official - Last Name:GIRARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:321-638-3931
Mailing Address - Street 1:1941 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-5728
Mailing Address - Country:US
Mailing Address - Phone:321-638-3931
Mailing Address - Fax:
Practice Address - Street 1:1941 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-5728
Practice Address - Country:US
Practice Address - Phone:321-638-3931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620988200Medicaid
FL620988200Medicaid