Provider Demographics
NPI:1336241462
Name:WEST COAST EYE INSTITUTE PA
Entity Type:Organization
Organization Name:WEST COAST EYE INSTITUTE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-726-6633
Mailing Address - Street 1:830 MEDICAL CT E
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4612
Mailing Address - Country:US
Mailing Address - Phone:352-726-6633
Mailing Address - Fax:352-726-9793
Practice Address - Street 1:830 MEDICAL CT E
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4612
Practice Address - Country:US
Practice Address - Phone:352-726-6633
Practice Address - Fax:352-726-9793
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST COAST EYE INSTITUTE PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-01
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0042680207W00000X
FLME0049134207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3784060602Medicaid
FL40218AOtherBLUE CROSS/BLUE SHIELD
FL0519570003Medicare NSC
FL40218AMedicare ID - Type Unspecified
0519570003Medicare NSC