Provider Demographics
NPI:1679554760
Name:BROOME, FRANK ANTHONY III (OD)
Entity type:Individual
Prefix:
First Name:FRANK
Middle Name:ANTHONY
Last Name:BROOME
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 SW MIDTOWN PL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0766
Mailing Address - Country:US
Mailing Address - Phone:386-466-1062
Mailing Address - Fax:386-466-1061
Practice Address - Street 1:125 SW MIDTOWN PL
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0766
Practice Address - Country:US
Practice Address - Phone:386-466-1062
Practice Address - Fax:386-466-1061
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2440152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078744200Medicaid
FL0787442200Medicare PIN
U09784Medicare UPIN
FL20221XMedicare PIN