Provider Demographics
NPI:1477531432
Name:OLDER, JAY JUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:JUSTIN
Last Name:OLDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 E FLETCHER AVE STE D
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4905
Mailing Address - Country:US
Mailing Address - Phone:813-971-3846
Mailing Address - Fax:813-977-2611
Practice Address - Street 1:4444 E FLETCHER AVE STE D
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4905
Practice Address - Country:US
Practice Address - Phone:813-971-3846
Practice Address - Fax:813-977-2611
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME21356207W00000X, 207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0021356OtherSTATE LICENSE #
FL1036672011OtherCIGNA
FL29789OtherBCBS INDIVIDUAL #
FL181907220OtherRAILROAD MEDICARE
FL624179OtherAETNA
FL29789OtherBCBS INDIVIDUAL #
FL29789ZMedicare PIN