Provider Demographics
NPI:1609560580
Name:JONES, DERWIN (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:
First Name:DERWIN
Middle Name:
Last Name:JONES
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2358 SE SHELTER DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4853
Mailing Address - Country:US
Mailing Address - Phone:954-257-1548
Mailing Address - Fax:
Practice Address - Street 1:1750 SW GATLIN BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2777
Practice Address - Country:US
Practice Address - Phone:772-878-1307
Practice Address - Fax:772-878-1309
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5848156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician