Provider Demographics
NPI:1750339289
Name:DAHLBERG, DEBRA J (OD)
Entity type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:J
Last Name:DAHLBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:DAHLBERG
Other - Last Name:BILLING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6152 DELANCEY STATION ST
Mailing Address - Street 2:STE 101
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-4206
Mailing Address - Country:US
Mailing Address - Phone:813-643-7300
Mailing Address - Fax:813-643-2276
Practice Address - Street 1:6152 DELANCEY STATION ST
Practice Address - Street 2:STE 101
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-4206
Practice Address - Country:US
Practice Address - Phone:813-643-7300
Practice Address - Fax:813-643-2276
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2269152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T12883Medicare UPIN
FL19578Medicare ID - Type Unspecified