Provider Demographics
NPI:1255448536
Name:JAY CRUMP OD PA
Entity type:Organization
Organization Name:JAY CRUMP OD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PARNELL
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:CRUMP
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:941-794-1333
Mailing Address - Street 1:5306 CORTEZ RD W
Mailing Address - Street 2:STE 3
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-2821
Mailing Address - Country:US
Mailing Address - Phone:941-794-1333
Mailing Address - Fax:941-794-5640
Practice Address - Street 1:5306 CORTEZ RD W
Practice Address - Street 2:STE 3
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-2821
Practice Address - Country:US
Practice Address - Phone:941-794-1333
Practice Address - Fax:941-794-5640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2343152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084786100Medicaid
FL084786100Medicaid
77721Medicare PIN