Provider Demographics
NPI:1023324795
Name:ZERMENO, JACQUELINE ELIZA (OD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELIZA
Last Name:ZERMENO
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 1:964 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1460
Mailing Address - Country:US
Mailing Address - Phone:321-253-3550
Mailing Address - Fax:321-253-3591
Practice Address - Street 1:3200 N WICKHAM RD
Practice Address - Street 2:STE 1
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2321
Practice Address - Country:US
Practice Address - Phone:321-253-3550
Practice Address - Fax:321-253-3591
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4604152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL56653400Medicaid
FLHW853YMedicare PIN
202I415489OtherRAILROAD MEDICARE
202I415489Medicare PIN