Provider Demographics
NPI:1003943242
Name:LAGE-SALTY, JENNIFER ELAINE (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ELAINE
Last Name:LAGE-SALTY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ELAINE
Other - Last Name:LAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:17120 ROYAL PALM BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326
Mailing Address - Country:US
Mailing Address - Phone:954-384-1127
Mailing Address - Fax:954-384-7105
Practice Address - Street 1:17120 ROYAL PALM BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326
Practice Address - Country:US
Practice Address - Phone:954-384-1127
Practice Address - Fax:954-384-7105
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3909152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621087200Medicaid