Provider Demographics
NPI:1609947696
Name:DESTIN EYE CARE PA
Entity Type:Organization
Organization Name:DESTIN EYE CARE PA
Other - Org Name:DR LOWERY HOUSTON SPARKS JR OD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OPTOMETRIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOWERY
Authorized Official - Middle Name:HOUSTON
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:850-650-0356
Mailing Address - Street 1:15017 EMERALD COAST PKWY
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541
Mailing Address - Country:US
Mailing Address - Phone:850-650-0356
Mailing Address - Fax:850-650-0355
Practice Address - Street 1:15017 EMERALD COAST PKWY
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541
Practice Address - Country:US
Practice Address - Phone:850-650-0356
Practice Address - Fax:850-650-0355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC003285152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20907Medicare ID - Type Unspecified
U77013Medicare UPIN