Basic Information
| Provider Information | |||||||||
| NPI: | 1316202401 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAKA | ||||||||
| FirstName: | DEDRIX | ||||||||
| MiddleName: | BENJAMIN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 8TH AVE W | ||||||||
| Address2: | STE 101 | ||||||||
| City: | PALMETTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342214737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417764008 | ||||||||
| FaxNumber: | 9418454963 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 N BREVARD AVE | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342664404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634917585 | ||||||||
| FaxNumber: | 8634917588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2012 | ||||||||
| LastUpdateDate: | 03/27/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC4785 | FL | Y | Eye and Vision Services Providers | Optometrist | 152WL0500X | 0618002165 | VA | N | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 013849400 | 05 | FL | MEDICAID | H04587 | 01 | FL | MEDICARE PTAN | OTHER |