Provider Demographics
NPI:1770764920
Name:L BRUCE FOSEN OD PA
Entity type:Organization
Organization Name:L BRUCE FOSEN OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:FOSEN
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:352-208-0091
Mailing Address - Street 1:2535 SE 28TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-6273
Mailing Address - Country:US
Mailing Address - Phone:352-208-0091
Mailing Address - Fax:
Practice Address - Street 1:2535 SE 28TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6273
Practice Address - Country:US
Practice Address - Phone:352-208-0091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 887152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078546600Medicaid
T93965Medicare UPIN
FL078546600Medicaid