Provider Demographics
NPI:1144254939
Name:DESTIN OPHTHALMOLOGY PA
Entity type:Organization
Organization Name:DESTIN OPHTHALMOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:G
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-622-0757
Mailing Address - Street 1:7700 US HIGHWAY 98 W
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-3270
Mailing Address - Country:US
Mailing Address - Phone:850-622-0757
Mailing Address - Fax:850-622-1978
Practice Address - Street 1:7700 US HIGHWAY 98 W
Practice Address - Street 2:SUITE 201
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-3270
Practice Address - Country:US
Practice Address - Phone:850-622-0757
Practice Address - Fax:850-622-1978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90933207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6880Medicare PIN
FL5865700001Medicare NSC