Provider Demographics
NPI:1750437786
Name:E TREVOR ELMQUIST D O P A
Entity type:Organization
Organization Name:E TREVOR ELMQUIST D O P A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:TREVOR
Authorized Official - Last Name:ELMQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:239-936-2020
Mailing Address - Street 1:7970 SUMMERLIN LAKES DR STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1855
Mailing Address - Country:US
Mailing Address - Phone:239-936-2020
Mailing Address - Fax:239-936-2776
Practice Address - Street 1:7970 SUMMERLIN LAKES DR STE 200
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1855
Practice Address - Country:US
Practice Address - Phone:239-936-2020
Practice Address - Fax:239-936-2776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4402207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80299YMedicare PIN
FLE72167Medicare UPIN
FL1091660001Medicare NSC