Provider Demographics
NPI:1780724112
Name:GULF COAST RETINA ASSOCIATES, LLC
Entity type:Organization
Organization Name:GULF COAST RETINA ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-862-3090
Mailing Address - Street 1:2055 LITTLE RD
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4421
Mailing Address - Country:US
Mailing Address - Phone:727-862-3090
Mailing Address - Fax:727-862-3023
Practice Address - Street 1:2055 LITTLE RD
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655
Practice Address - Country:US
Practice Address - Phone:727-862-3090
Practice Address - Fax:727-862-3023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68907207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379522500Medicaid
FL379522500Medicaid
FLF42123Medicare UPIN