Provider Demographics
NPI:1588182562
Name:COREN EYE GROUP PLLC
Entity Type:Organization
Organization Name:COREN EYE GROUP PLLC
Other - Org Name:EYECARE CENTER OF LEESBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:VU
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:407-256-3763
Mailing Address - Street 1:4137 BRIAR GATE LN
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5521
Mailing Address - Country:US
Mailing Address - Phone:407-256-3763
Mailing Address - Fax:407-386-7664
Practice Address - Street 1:112 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6350
Practice Address - Country:US
Practice Address - Phone:352-787-1956
Practice Address - Fax:352-365-6690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-30
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4108152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621137200Medicaid