Provider Demographics
NPI:1184883662
Name:ABC OPTOMETRY INC
Entity type:Organization
Organization Name:ABC OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:YACOUB
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:786-239-8279
Mailing Address - Street 1:1525 ANCONA AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-1905
Mailing Address - Country:US
Mailing Address - Phone:786-239-8279
Mailing Address - Fax:
Practice Address - Street 1:8748 BIRD RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-5471
Practice Address - Country:US
Practice Address - Phone:305-227-5467
Practice Address - Fax:305-227-5895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3844152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000065000Medicaid