Provider Demographics
NPI:1376527705
Name:JICHA, JOHN JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:JICHA
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 1:2607 BURCH POINT
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-9333
Mailing Address - Country:US
Mailing Address - Phone:336-869-3432
Mailing Address - Fax:336-889-2252
Practice Address - Street 1:3911 FOUNTAIN GROVE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-8032
Practice Address - Country:US
Practice Address - Phone:336-889-2225
Practice Address - Fax:336-889-2252
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1391152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015MCMedicaid
09458OtherBCBS
NC8909438Medicaid
015MCOtherBCBS GROUP
1391OtherNC LICENSE
NC89015MCMedicaid
1391OtherNC LICENSE
NC8909438Medicaid