Provider Demographics
NPI:1679764617
Name:EYE DOCTORS OPTICAL OUTLETS PA
Entity Type:Organization
Organization Name:EYE DOCTORS OPTICAL OUTLETS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWENSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:813-885-3937
Mailing Address - Street 1:5607 JOHNS RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-4317
Mailing Address - Country:US
Mailing Address - Phone:813-885-3937
Mailing Address - Fax:
Practice Address - Street 1:4121 US HIGHWAY 98 N
Practice Address - Street 2:#A-140
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-3818
Practice Address - Country:US
Practice Address - Phone:863-859-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620937831Medicaid
FLK4770Medicare PIN