Provider Demographics
NPI:1245296599
Name:KANICKY, JEE ME (OD)
Entity type:Individual
Prefix:DR
First Name:JEE
Middle Name:ME
Last Name:KANICKY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JEE
Other - Middle Name:M
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:21517 VILLAGE LAKES SHOPPING CTR DR
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-5101
Practice Address - Country:US
Practice Address - Phone:813-949-0421
Practice Address - Fax:813-949-0351
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 003907152WP0200X
FLOPC3907152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPC 003907OtherSTATE LICENSE
FLU97328Medicare UPIN