Provider Demographics
NPI:1689711194
Name:HARRELL, ALBERT L III (OD )
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:L
Last Name:HARRELL
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11924 W FOREST HILL BLVD
Mailing Address - Street 2:SUITE 31
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6256
Mailing Address - Country:US
Mailing Address - Phone:561-798-8282
Mailing Address - Fax:561-798-2840
Practice Address - Street 1:11924 W FOREST HILL BLVD
Practice Address - Street 2:SUITE 31
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6256
Practice Address - Country:US
Practice Address - Phone:561-798-8282
Practice Address - Fax:561-798-2840
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP 1746152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19649BOtherPTAN
FL078294700Medicaid
FL0776020002Medicare NSC
FL078294700Medicaid
FL19649BMedicare PIN