Provider Demographics
NPI:1124545827
Name:PATHIYIL, JENNIFER ANN (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:PATHIYIL
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 1:11645 BISCAYNE BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33181-3138
Mailing Address - Country:US
Mailing Address - Phone:305-538-8835
Mailing Address - Fax:305-938-4044
Practice Address - Street 1:11645 BISCAYNE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33181-3138
Practice Address - Country:US
Practice Address - Phone:305-538-8835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5424152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101304000Medicaid