Provider Demographics
NPI:1710919170
Name:AVONDA, WILLIAM MARK (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MARK
Last Name:AVONDA
Suffix:
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:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-0489
Mailing Address - Country:US
Mailing Address - Phone:386-755-2785
Mailing Address - Fax:386-755-1128
Practice Address - Street 1:1615 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1108
Practice Address - Country:US
Practice Address - Phone:386-755-2785
Practice Address - Fax:386-755-1128
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3868152W00000X
FLOB3177152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1180560001OtherMEDICARE DMERC
FL25000OtherBLUE CROSS BLUE SHIELD
FL620978500Medicaid
FL001933700Medicaid
FL297390OtherAVMED
FL620978501Medicaid
FL7155780OtherAETNA
P00208868OtherRAILROAD MEDICARE
FL25000OtherBLUE CROSS BLUE SHIELD
FL001933700Medicaid
FLU4084ZMedicare PIN