Provider Demographics
NPI:1750322871
Name:HENDRIX, DAVID DONALD (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:DONALD
Last Name:HENDRIX
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 1:1917 KNOX MCRAE DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5360
Mailing Address - Country:US
Mailing Address - Phone:321-383-1332
Mailing Address - Fax:321-383-1243
Practice Address - Street 1:1917 KNOX MCRAE DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5360
Practice Address - Country:US
Practice Address - Phone:321-383-1332
Practice Address - Fax:321-383-1243
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3713152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1750322871OtherNPI
FL20033OtherBCBS FL
FL620828200Medicaid
FL20033OtherBCBS FL
FL620828200Medicaid
FL0539980003Medicare NSC
FL20033ZMedicare PIN
FLU95236Medicare UPIN
FL592616886OtherGROUP TAX ID