Basic Information
| Provider Information | |||||||||
| NPI: | 1497859094 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAMES A HALEY VA MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DEPARTMENT OF VETERANS AFFAIRS | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13000 BRUCE B DOWNS BLVD | ||||||||
| Address2: | VIST COORDINATOR 130V | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336124745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139722000 | ||||||||
| FaxNumber: | 8136317142 | ||||||||
| Practice Location | |||||||||
| Address1: | 13000 BRUCE B DOWNS BLVD | ||||||||
| Address2: | VIST COORDINATOR 130V | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336124745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139722000 | ||||||||
| FaxNumber: | 8136317142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KIRK | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF, OPHTHALMOLOGY | ||||||||
| AuthorizedOfficialTelephone: | 8139722000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.