Provider Demographics
NPI:1619927597
Name:PHILIPPE, JACK JAY (OD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:JAY
Last Name:PHILIPPE
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 1:201 S WILCOX ST
Mailing Address - Street 2:PO BOX 881
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-3315
Mailing Address - Country:US
Mailing Address - Phone:303-660-0044
Mailing Address - Fax:303-660-6219
Practice Address - Street 1:201 S WILCOX ST
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-3315
Practice Address - Country:US
Practice Address - Phone:303-660-0044
Practice Address - Fax:303-660-6219
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO1199152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1273750001Medicare NSC
COC43343Medicare PIN