Provider Demographics
NPI:1235182478
Name:MOENNIG, JAN L (OD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:L
Last Name:MOENNIG
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 1:900 N BELCHER RD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-2105
Mailing Address - Country:US
Mailing Address - Phone:727-447-5466
Mailing Address - Fax:727-449-0616
Practice Address - Street 1:900 N BELCHER RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-2105
Practice Address - Country:US
Practice Address - Phone:727-447-5466
Practice Address - Fax:727-449-0616
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL02200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19688Medicare PIN
FL1194100001Medicare NSC
FLT24812Medicare UPIN