Provider Demographics
NPI:1912002395
Name:EYE CENTER OF NORTH FLORIDA, P.A.
Entity Type:Organization
Organization Name:EYE CENTER OF NORTH FLORIDA, P.A.
Other - Org Name:PORT ST. JOE OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-784-3937
Mailing Address - Street 1:2500 MARTIN LUTHER KING JR. BLVD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4412
Mailing Address - Country:US
Mailing Address - Phone:850-784-3937
Mailing Address - Fax:850-522-9829
Practice Address - Street 1:528B 5TH ST
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1754
Practice Address - Country:US
Practice Address - Phone:850-227-7266
Practice Address - Fax:850-229-2595
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYE CENTER OF NORTH FLORIDA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-13
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1740213529OtherGROUP NPI
FLCG6943OtherRR MEDICARE
FL257952901Medicaid
FL45154COtherBLUE CROSS & BLUE SHIELD
FLCG6943OtherRR MEDICARE
FLK1483Medicare ID - Type Unspecified