Provider Demographics
NPI:1568865038
Name:ST PETERSBURG EYE CARE SPECIALISTS P.A.
Entity Type:Organization
Organization Name:ST PETERSBURG EYE CARE SPECIALISTS P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMARGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-543-2928
Mailing Address - Street 1:929 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1501
Mailing Address - Country:US
Mailing Address - Phone:727-898-3155
Mailing Address - Fax:
Practice Address - Street 1:929 1ST AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1501
Practice Address - Country:US
Practice Address - Phone:727-898-3155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-29
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4723152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006512300Medicaid