Provider Demographics
NPI:1629326343
Name:ST JOHNS EYE ASSOCIATES AT NOCATEE
Entity Type:Organization
Organization Name:ST JOHNS EYE ASSOCIATES AT NOCATEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BACKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-433-2901
Mailing Address - Street 1:100 MARKETSIDE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0582
Mailing Address - Country:US
Mailing Address - Phone:904-825-4525
Mailing Address - Fax:904-825-4520
Practice Address - Street 1:200 NOCATEE VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081
Practice Address - Country:US
Practice Address - Phone:904-825-4525
Practice Address - Fax:904-825-4520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3241152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty