Provider Demographics
NPI:1770837874
Name:FLORIDA PEDIATRIC EYE SPECIALISTS, INC
Entity Type:Organization
Organization Name:FLORIDA PEDIATRIC EYE SPECIALISTS, INC
Other - Org Name:GIACOMO S GUGGINO MD PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:813-681-1122
Mailing Address - Street 1:403 VONDERBURG DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5982
Mailing Address - Country:US
Mailing Address - Phone:813-681-1122
Mailing Address - Fax:813-684-4924
Practice Address - Street 1:3115 W SWANN AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4617
Practice Address - Country:US
Practice Address - Phone:813-879-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0537934-00Medicaid