Provider Demographics
NPI:1164730297
Name:JAY ROSENFELD OD PA
Entity Type:Organization
Organization Name:JAY ROSENFELD OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENFELD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:727-799-4500
Mailing Address - Street 1:2541 COUNTRYSIDE BLVD STE 1
Mailing Address - Street 2:
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 STE 1
Practice Address - Street 2:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1691152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL086557500Medicaid
FL1114924040OtherINDIVIDUAL NPI FOR JAY ROSENFELD OD
FL086557500Medicaid
FL1114924040OtherINDIVIDUAL NPI FOR JAY ROSENFELD OD