Provider Demographics
NPI:1720025711
Name:PASTORE, DOMINIC JAMES (OD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:JAMES
Last Name:PASTORE
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 560580
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-0580
Mailing Address - Country:US
Mailing Address - Phone:321-693-1534
Mailing Address - Fax:321-259-4658
Practice Address - Street 1:1000 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8937
Practice Address - Country:US
Practice Address - Phone:321-259-1699
Practice Address - Fax:321-259-4658
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3723152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20680OtherBCBS OF FL
FL620836300Medicaid
FL20680YMedicare PIN
FL0539980002Medicare NSC
FL0539980001Medicare NSC
FLU96174Medicare UPIN
FLP00074649Medicare PIN
FL20680OtherBCBS OF FL
FL0539980005Medicare NSC
FL0539980003Medicare NSC
FL620836300Medicaid