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NPI 1174694376 SIDMAN KARA BACHUS O.D. _ F.A.A.O

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NPI 1174694376 SIDMAN KARA BACHUS O.D. _ F.A.A.O Powered By Docstoc
					                                                                                                                                                   HIPAASpace NPI Form
WWW.HIPAASPACE.COM                                                                                                                                    Source NPI Lookup


                              NATIONAL PROVIDER IDENTIFIER (NPI) FORM
Information provided in the current document is obtained from official source and accuracy of the information provided is the sole
responsibility of the healthcare provide. All changes, corrections or updates must be done through the official sources. Please contact
HIPAASpace.com in case you need the assistance in obtaining the official contacts of corresponding government organizations.

SECTION 1 – BASIC INFORMATION
 NPI Number          Provider (Organization) Full Name                  Provider (Organization) Other Name                         Entity Type          Replacement NPI

 1174694376            SIDMAN KARA BACHUS O.D. , F.A.A.O.                                                                          Individual
 Gender        Enumeration Date     Last Update Date     Deactivation Reason Code      Deactivation Date       Reactivation Date    Employer Identification Number (EIN)

 Female        11/11/2006           12/17/2008

SECTION 2 – CONTACT INFORMATION
 Business Mailing Address

 1070 GREENWOOD BLVD , LAKE MARY FL327465404-327465404 US
 Practice Location Address

 1070 GREENWOOD BLVD , LAKE MARY FL327465404-327465404 US
 Business Phone Number                       Business Fax Number                            Practice Phone Number                            Practice Fax Number

 4073335111                                  4073332434                                     4073335111                                       4073332434
 Authorized Official – Name                                                         Authorized Official – Title/Position              Authorized Official - Phone Number




SECTION 3 – LICENSING, IDENTIFICATION INFORMATION

A. TAXONOMY INFORMATION

1. Code: 152W00000X (Optometrist). License Number : OPC2970 FL.




B. OTHER PROVIDER IDENTIFIERS

1. Identifier: 410034015. Type: MEDICARE PIN. FL.
2. Identifier: 620239000. Type: MEDICAID. FL.
3. Identifier: 20726. Type: OTHER. FL. Issuer: BCBSFL.
4. Identifier: U64635. Type: MEDICARE UPIN. FL.
5. Identifier: 8089335. Type: OTHER. FL. Issuer: CIGNA.
6. Identifier: 20726Y. Type: MEDICARE PIN. FL.
7. Identifier: 5271200. Type: OTHER. FL. Issuer: AETNA.
8. Identifier: 20726X. Type: MEDICARE PIN. FL.
9. Identifier: 6599986. Type: OTHER. FL. Issuer: GHI.




www.hipaaspace.com                                                 NPI Profile: 1174694376 SIDMAN KARA BACHUS O.D. , F.A.A.O.

				
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