Individual
DR. AMANDA J. BOURGEOIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OD
Contact information
Practice address
807 CHILDRENS WAY, JACKSONVILLE, FL 32207-8426
(904) 390-3705
(904) 390-3502
Mailing address
PO BOX 191, PROVIDER ENROLLMENT DEPT, ROCKLAND, DE 19732-0191
(302) 651-6212
(302) 651-4945
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
OPC3215
FL
152WP0200X
Pediatric Optometrist
Primary
OPC3215
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000901117A
—
GA
05
—
620608500
—
FL
Enumeration date
08/10/2006
Last updated
09/07/2011
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