Provider Demographics
NPI:1508182577
Name:EYE SPECIALISTS LASER & SURGERY CENTER INC
Entity Type:Organization
Organization Name:EYE SPECIALISTS LASER & SURGERY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOROVOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-939-1444
Mailing Address - Street 1:12453 S CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3828
Mailing Address - Country:US
Mailing Address - Phone:239-939-1444
Mailing Address - Fax:239-275-3332
Practice Address - Street 1:12453 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3828
Practice Address - Country:US
Practice Address - Phone:239-939-1444
Practice Address - Fax:239-275-3332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF1554OtherMEDICARE
FLP00936589OtherRR MEDICARE
FL003297700Medicaid
FL1508182577OtherUNITED HEALTHCARE
FL6CGOtherBC/BS