Provider Demographics
NPI:1043526205
Name:DR R KEITH AMIEL-OPTOMETRIST P A
Entity type:Organization
Organization Name:DR R KEITH AMIEL-OPTOMETRIST P A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:R.
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:AMIEL
Authorized Official - Suffix:
Authorized Official - Credentials:-OPTOMETRIST P A
Authorized Official - Phone:850-243-3111
Mailing Address - Street 1:36 EGLIN PKWY NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4915
Mailing Address - Country:US
Mailing Address - Phone:850-243-3111
Mailing Address - Fax:850-200-4373
Practice Address - Street 1:36 EGLIN PKWY NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4915
Practice Address - Country:US
Practice Address - Phone:850-243-3111
Practice Address - Fax:850-200-4373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC874152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19461OtherBCBS
FL078299300Medicaid
FL1260030001Medicare NSC
FL19461OtherBCBS