Provider Demographics
NPI:1295728418
Name:UNDERILL, DAVID JAMES (OD)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JAMES
Last Name:UNDERILL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S PARROTT AVE
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-4345
Mailing Address - Country:US
Mailing Address - Phone:863-763-4334
Mailing Address - Fax:863-763-3226
Practice Address - Street 1:520 S PARROTT AVE
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34974-4345
Practice Address - Country:US
Practice Address - Phone:863-763-4334
Practice Address - Fax:863-763-3226
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0PC001869152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL410044369OtherRAILROAD MEDICARE
FL410044369Medicare PIN
FL410044369OtherRAILROAD MEDICARE
FL07B280700Medicare ID - Type Unspecified
FL19779Medicare ID - Type Unspecified
FL19779Medicare PIN