Provider Demographics
NPI:1780475624
Name:BARSOUM, MYRNA (OD)
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:BARSOUM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 WHEELHOUSE LN
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-0016
Mailing Address - Country:US
Mailing Address - Phone:321-506-5964
Mailing Address - Fax:
Practice Address - Street 1:340 WHEELHOUSE LN
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-0016
Practice Address - Country:US
Practice Address - Phone:321-506-5964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6606152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist