Provider Demographics
NPI:1679505226
Name:JELLENEK, GREGORY PAUL (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:PAUL
Last Name:JELLENEK
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 1:5251-18 JOHN TYLER HWY.
Mailing Address - Street 2:#353
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-8808
Mailing Address - Country:US
Mailing Address - Phone:757-963-1863
Mailing Address - Fax:757-963-1881
Practice Address - Street 1:BLDG. 1527
Practice Address - Street 2:
Practice Address - City:FT. EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-1618
Practice Address - Country:US
Practice Address - Phone:757-887-3627
Practice Address - Fax:757-887-0403
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000342152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010045711Medicaid
410001213Medicare ID - Type Unspecified
T70270Medicare UPIN