Provider Demographics
NPI:1518198027
Name:PAYNE, TESSA (OD)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:PAYNE
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 1:3132 SAGO POINT CT
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-6781
Mailing Address - Country:US
Mailing Address - Phone:716-338-7276
Mailing Address - Fax:
Practice Address - Street 1:6905 MEDICAL VIEW LN
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542-6648
Practice Address - Country:US
Practice Address - Phone:813-788-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002249152W00000X
DEI3-0001336152W00000X
COOPT0002867152W00000X
FLOPC 5005152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020708100Medicaid
FL020708100Medicaid