Provider Demographics
NPI:1578753984
Name:VANEK, JESSICA MARIE (O D)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:VANEK
Suffix:
Gender:F
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 S GOVERNORS AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-4158
Mailing Address - Country:US
Mailing Address - Phone:302-734-5861
Mailing Address - Fax:302-734-1921
Practice Address - Street 1:885 S GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4158
Practice Address - Country:US
Practice Address - Phone:302-734-5861
Practice Address - Fax:302-734-1921
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE13-0001322152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578753984OtherNPI
DEG00016OtherMEDICARE GROUP PTAN
DE022837H16OtherMEDICARE INDIVIDUAL PTAN
DE13-0001322OtherDELAWARE LICENSE