Provider Demographics
NPI:1114924040
Name:ROSENFELD, JAY (OD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:ROSENFELD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2541 COUNTRYSIDE BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-3504
Mailing Address - Country:US
Mailing Address - Phone:727-799-4500
Mailing Address - Fax:727-724-1633
Practice Address - Street 1:2541 COUNTRYSIDE BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3504
Practice Address - Country:US
Practice Address - Phone:727-799-4500
Practice Address - Fax:727-724-1633
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2010-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP1691152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL086557500Medicaid
FL592932410OtherTAX ID
FLOP1691OtherSTATE LICENSE NUMBER
FLOC208OtherSTATE PHARMACOLOGY NUMBER
FL592932410OtherTAX ID
FLOP1691OtherSTATE LICENSE NUMBER
FL086557500Medicaid