Provider Demographics
NPI:1629493887
Name:COUNTRYWAY EYECARE
Entity Type:Organization
Organization Name:COUNTRYWAY EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSOFF
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:813-925-3393
Mailing Address - Street 1:6911 PISTOL RANGE RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635-6335
Mailing Address - Country:US
Mailing Address - Phone:813-925-3393
Mailing Address - Fax:813-925-3394
Practice Address - Street 1:6911 PISTOL RANGE RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-6335
Practice Address - Country:US
Practice Address - Phone:813-925-3393
Practice Address - Fax:813-925-3394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP3810152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU79045Medicare UPIN