Provider Demographics
NPI:1972111847
Name:PHILLIPS, JHALEIL (OD)
Entity Type:Individual
Prefix:
First Name:JHALEIL
Middle Name:
Last Name:PHILLIPS
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 1:161 HAMPTON POINT DR STE 3
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3058
Mailing Address - Country:US
Mailing Address - Phone:904-287-9137
Mailing Address - Fax:904-287-9057
Practice Address - Street 1:161 HAMPTON POINT DR STE 3
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3058
Practice Address - Country:US
Practice Address - Phone:904-287-9137
Practice Address - Fax:904-287-9057
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003263152W00000X
FLOPC5992152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist