Provider Demographics
NPI:1508965104
Name:MEMOLI, KAREN M (OD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:M
Last Name:MEMOLI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21275 OLEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6703
Mailing Address - Country:US
Mailing Address - Phone:941-625-1325
Mailing Address - Fax:941-423-8618
Practice Address - Street 1:21275 OLEAN BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6703
Practice Address - Country:US
Practice Address - Phone:941-625-1325
Practice Address - Fax:941-423-8618
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3367152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620459700Medicaid
FL77323Medicare UPIN
FL3184 DMedicare ID - Type UnspecifiedINDIVIDUAL