Provider Demographics
NPI:1689921389
Name:FLORIDA OPHTHALMIC AFFILIATES, PA
Entity type:Organization
Organization Name:FLORIDA OPHTHALMIC AFFILIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:855-989-2020
Mailing Address - Street 1:348 MIRACLE STRIP PKWY SW
Mailing Address - Street 2:SUITE 38
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5200
Mailing Address - Country:US
Mailing Address - Phone:855-989-2020
Mailing Address - Fax:855-989-2020
Practice Address - Street 1:1300 SHORELINE DRIVE
Practice Address - Street 2:SUITE 104
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4766
Practice Address - Country:US
Practice Address - Phone:855-989-2020
Practice Address - Fax:855-290-5952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85614207W00000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006482200Medicaid
FL006482201Medicaid
FLGN857AMedicare PIN
FLGN857BMedicare PIN