Provider Demographics
NPI:1063509925
Name:CEONZO, JENNIFER MEGAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MEGAN
Last Name:CEONZO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WINDSOR PL
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-1331
Mailing Address - Country:US
Mailing Address - Phone:631-673-1950
Mailing Address - Fax:
Practice Address - Street 1:150 BROADHOLLOW RD STE 104
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4901
Practice Address - Country:US
Practice Address - Phone:631-791-5155
Practice Address - Fax:631-791-5154
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006541152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY142555POtherHIP PROVIDER NUMBER
NYU98514Medicare UPIN
NY142555POtherHIP PROVIDER NUMBER