Provider Demographics
NPI:1922215136
Name:OPTIMART, INC.
Entity Type:Organization
Organization Name:OPTIMART, INC.
Other - Org Name:OPTIMART, INC. #05
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-526-0501
Mailing Address - Street 1:4359 35TH ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33714-3717
Mailing Address - Country:US
Mailing Address - Phone:727-914-8615
Mailing Address - Fax:727-914-8610
Practice Address - Street 1:10755 PARK BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-5420
Practice Address - Country:US
Practice Address - Phone:727-392-0907
Practice Address - Fax:727-592-2569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOE379156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL630126600Medicaid
FL630126600Medicaid