Provider Demographics
NPI:1013124882
Name:OPTIMART, INC.
Entity Type:Organization
Organization Name:OPTIMART, INC.
Other - Org Name:OPTIMART, INC. #12
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:727-914-8615
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 1:2637 E GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34453-3216
Practice Address - Country:US
Practice Address - Phone:352-637-5180
Practice Address - Fax:352-637-5181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOE386156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL630126600Medicaid
FL0895780023Medicare ID - Type UnspecifiedPROVIDER NUMBER