Provider Demographics
NPI:1831466358
Name:MIAMI SHORES OPTICAL INC.
Entity Type:Organization
Organization Name:MIAMI SHORES OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:CONSTANTINE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:786-313-3048
Mailing Address - Street 1:9440 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-2703
Mailing Address - Country:US
Mailing Address - Phone:786-313-3048
Mailing Address - Fax:786-313-3051
Practice Address - Street 1:9440 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33138-2703
Practice Address - Country:US
Practice Address - Phone:786-313-3048
Practice Address - Fax:786-313-3051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620628000Medicaid
FL620628000Medicaid