Provider Demographics
NPI:1376761072
Name:JACQUELINE Z FAY OD PA
Entity Type:Organization
Organization Name:JACQUELINE Z FAY OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:Z
Authorized Official - Last Name:FAY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:941-497-4451
Mailing Address - Street 1:1531 TAMIAMI TRL S
Mailing Address - Street 2:SUITE 702A
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-5570
Mailing Address - Country:US
Mailing Address - Phone:941-497-4451
Mailing Address - Fax:941-408-8971
Practice Address - Street 1:1531 TAMIAMI TRL S
Practice Address - Street 2:SUITE 702A
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-5570
Practice Address - Country:US
Practice Address - Phone:941-497-4451
Practice Address - Fax:941-408-8971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSL2513152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1811086812OtherNPI
FL20772Medicare ID - Type UnspecifiedMEDICARE PROVIDER
FL1811086812OtherNPI