Provider Demographics
NPI:1366268203
Name:JEOBOAM, EMMANUEL
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:JEOBOAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 W ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-5296
Mailing Address - Country:US
Mailing Address - Phone:954-957-7179
Mailing Address - Fax:954-975-7367
Practice Address - Street 1:5555 W ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5296
Practice Address - Country:US
Practice Address - Phone:954-975-7179
Practice Address - Fax:954-954-9757
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6534156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician