Romanda Basaly Demetrios, O.D.
Individual provider Active NPI Optometrist · Saint Johns, FL
NPI 1003243502 · NPPES record last updated Jul 19, 2022
Key facts
- NPI
- 1003243502
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Optometrist 152W00000X
- License
- OPC6053 (FL)
- Practice address
- 155 Fountains Way Ste 11
Saint Johns, FL 32259-1144 - Phone
- (404) 932-2802
- NPI assigned
- Sep 30, 2013
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in FL
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20221014002843 | FL | Practitioner - Optometry | 8628209087 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| OPC6053 | FL | MD | Optometrist |
| OPT002962 | GA | MD | Optometrist |
| 4901004806 | MI | MD | Optometrist |
| 002962 | GA | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Coastal Clear Eyecare | Optometrist | Current |
Accepting new patients |
| Myeyedr Optometry of Georgia, LLC | Optometrist | Past | Accepting new patients |
Locations
155 Fountains Way
Ste 11
Saint Johns, FL 32259
Phone (404) 932-2802
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 4901004806 | MI | |
| Optometrist | 152W00000X | OPT002962 | GA | |
| Optometrist | 152W00000X | OPC6053 | FL | Yes |
Addresses
Primary practice location
155 Fountains Way Ste 11
Saint Johns, FL 32259-1144
Mailing address
133 Rum Runner Way
Saint Johns, FL 32259-2267
Phone (404) 932-2802
Other providers in Saint Johns, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 19, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.