Provider Demographics
NPI:1598729352
Name:FAMILY EYE CARE CENTER OF JACKSONVILLE PA
Entity Type:Organization
Organization Name:FAMILY EYE CARE CENTER OF JACKSONVILLE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KOENIGSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-996-7774
Mailing Address - Street 1:8833 PERIMETER PARK BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1110
Mailing Address - Country:US
Mailing Address - Phone:904-996-7774
Mailing Address - Fax:904-996-9511
Practice Address - Street 1:8833 PERIMETER PARK BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1110
Practice Address - Country:US
Practice Address - Phone:904-996-7774
Practice Address - Fax:904-996-9511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75604207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259193600Medicaid
FL259193600Medicaid
FL46422WMedicare PIN