Provider Demographics
NPI:1922865823
Name:JEAN-BAPTISTE, ELISSAGE (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:
First Name:ELISSAGE
Middle Name:
Last Name:JEAN-BAPTISTE
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 1:18572 SW 42ND ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-2774
Mailing Address - Country:US
Mailing Address - Phone:786-205-2887
Mailing Address - Fax:
Practice Address - Street 1:12555 W SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-0900
Practice Address - Country:US
Practice Address - Phone:954-845-0647
Practice Address - Fax:954-845-0289
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5135152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision