Provider Demographics
NPI:1659335289
Name:FAY, JEROME ALLAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:ALLAN
Last Name:FAY
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 1:1600 VIEWCREST CIR
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-5387
Mailing Address - Country:US
Mailing Address - Phone:952-898-0513
Mailing Address - Fax:651-646-3761
Practice Address - Street 1:1560 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3908
Practice Address - Country:US
Practice Address - Phone:651-646-8889
Practice Address - Fax:651-646-3761
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2684152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2201029OtherMEDICA
MN140179OtherUCARE
MN32F04FAOtherBLUE CROSS/BLUE SHIELD
MNMEDICAL ASSISTANCEOtherMINNESOTA
MN40288OtherCOLE MANAGED VISION
MNMEDICAL ASSISTANCEOtherMINNESOTA
MN140179OtherUCARE