Provider Demographics
NPI:1639325434
Name:SUPER OPTICAL EXPRESS
Entity Type:Organization
Organization Name:SUPER OPTICAL EXPRESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:FUNDERBURK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:352-331-2040
Mailing Address - Street 1:6757 W NEWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4312
Mailing Address - Country:US
Mailing Address - Phone:352-331-2040
Mailing Address - Fax:352-331-1526
Practice Address - Street 1:6757 W NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4312
Practice Address - Country:US
Practice Address - Phone:352-331-2040
Practice Address - Fax:352-331-1526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL796152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084305900Medicaid
FL084871900Medicaid