Provider Demographics
NPI:1831282805
Name:JOLY, SANDRA D (OD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:D
Last Name:JOLY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9280 STARPASS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-519-6141
Mailing Address - Fax:
Practice Address - Street 1:4668 TOWN CROSSING DR STE 143
Practice Address - Street 2:INSIDE LENSCRAFTERS
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-7422
Practice Address - Country:US
Practice Address - Phone:904-641-1684
Practice Address - Fax:904-641-1582
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0PC0002714152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL122070OtherEYEMED
U45451Medicare UPIN