NPIMap

Organization Active NPI

St Johns Eye Associates PA

  • Optometrist
  • Jacksonville, FL
National Provider Identifier
1609502178
Registry record updated Jul 27, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
Legal business name
ST JOHNS EYE ASSOCIATES PA
Practice address
2039 Hendricks Avenue
Unit 213
Jacksonville, FL 32207-3209
Phone
(904) 287-9137
Fax
(904) 287-9057
NPI assigned
Jul 27, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 27, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Donna Marie Backs
Title
Credentialing
Phone
(805) 433-2901

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193400000X SINGLE SPECIALTY GROUP 152W00000X Primary

Addresses

Primary practice location

2039 Hendricks Avenue
Unit 213
Jacksonville, FL 32207-3209

Mailing address

161 Hampton Point Dr Ste 3
St Augustine, FL 32092-3058
Phone (805) 433-2901

Other names 1

  • St Johns Eye Associates at San Marco Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100225000113 FL Part B Supplier - Clinic/Group Practice 6406990605 Receives reassigned benefits from 12 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Saint Augustine, FL; St Augustine, FL; Ponte Vedra, FL; Jacksonville, FL

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D2270472St Johns Eye Associates, PA2039 Hendricks Ave Unit 213, Jacksonville, FL 32207Certificate of waiverOct 16, 2026

National Provider Directory

National Provider Directory
Tax ID family
St Johns Eye Associates at Nocatee3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

2039 Hendricks Ave
Ste 213
Jacksonville, FL 32207
Phone (904) 560-6962

161 Hampton Point Dr
Ste 3
Saint Augustine, FL 32092
Phone (904) 204-3345

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1658880000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658880000000",
    "number": "1609502178",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "161 HAMPTON POINT DR STE 3",
            "city": "ST AUGUSTINE",
            "state": "FL",
            "postal_code": "320923058",
            "telephone_number": "805-433-2901"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2039 HENDRICKS AVENUE",
            "address_2": "UNIT 213",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322073209",
            "telephone_number": "904-287-9137",
            "fax_number": "904-287-9057"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST JOHNS EYE ASSOCIATES PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-07-27",
        "last_updated": "2022-07-27",
        "certification_date": "2022-06-30",
        "status": "A",
        "authorized_official_last_name": "BACKS",
        "authorized_official_first_name": "DONNA",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "805-433-2901"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St Johns Eye Associates at San Marco",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Jacksonville, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 27, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.