Provider Demographics
NPI:1992853444
Name:DE JENGA, ISAAC CHINE (OD)
Entity Type:Individual
Prefix:DR
First Name:ISAAC
Middle Name:CHINE
Last Name:DE JENGA
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 1:3820 STATE HIGHWAY 64 W
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-6924
Mailing Address - Country:US
Mailing Address - Phone:903-526-3937
Mailing Address - Fax:
Practice Address - Street 1:3820 STATE HIGHWAY 64 W
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75704-6924
Practice Address - Country:US
Practice Address - Phone:903-526-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6165 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
30189OtherSUPERIOR VISION
454178OtherNVA
920804OtherBLOCK VISION
26336OtherM EDICAL EYE SERVICES
19694OtherLIFE RE
10823OtherSVS FORD
0051FCOtherBLUE CROSS BLUE SHIELD
19694OtherLIFE RE
454178OtherNVA