Active NPI
John Tivnan, O.D.
- Optometrist
- Winter Haven, FL
National Provider Identifier
1013911379
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- OPC 1060
- Practice address
- 407 Avenue K SE
Winter Haven, FL 33880-4126 - Phone
- (863) 294-3504
- Fax
- (863) 299-0096
- NPI assigned
- Jun 2, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | OPC 1060 | FL | Primary |
Addresses
Primary practice location
407 Avenue K SE
Winter Haven, FL 33880-4126
Mailing address
407 Avenue K SE
Winter Haven, FL 33880-4126
Phone (863) 294-3504
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 078082100 | Medicaid | FL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| OPC 1060 | FL | MD | Optometrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1117670400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1013911379",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "407 AVENUE K SE",
"city": "WINTER HAVEN",
"state": "FL",
"postal_code": "338804126",
"telephone_number": "863-294-3504",
"fax_number": "863-299-0096"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "407 AVENUE K SE",
"city": "WINTER HAVEN",
"state": "FL",
"postal_code": "338804126",
"telephone_number": "863-294-3504",
"fax_number": "863-299-0096"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TIVNAN",
"first_name": "JOHN",
"name_prefix": "Dr.",
"credential": "O.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-06-02",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "FL",
"license": "OPC 1060",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "078082100",
"state": "FL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Winter Haven, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.