Provider Demographics
NPI:1881852291
Name:FLEMING ISLAND 2020 PA
Entity Type:Organization
Organization Name:FLEMING ISLAND 2020 PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAROKH
Authorized Official - Middle Name:
Authorized Official - Last Name:KAPADIA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-287-9137
Mailing Address - Street 1:161 HAMPTON POINT DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3057
Mailing Address - Country:US
Mailing Address - Phone:904-287-9137
Mailing Address - Fax:
Practice Address - Street 1:1505 COUNTY ROAD 220
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-7926
Practice Address - Country:US
Practice Address - Phone:904-215-3005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3241152W00000X
FLOPC3594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620800200Medicaid
FL620801100Medicaid
FL620801100Medicaid
FLU85905Medicare UPIN