Provider Demographics
NPI:1265414064
Name:PASS, JEFFERY JAY (OD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:JAY
Last Name:PASS
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 1:2200 ELMWOOD AVE
Mailing Address - Street 2:STE D-4
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2347
Mailing Address - Country:US
Mailing Address - Phone:765-446-2814
Mailing Address - Fax:765-447-2870
Practice Address - Street 1:2200 ELMWOOD AVE
Practice Address - Street 2:STE D-4
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2347
Practice Address - Country:US
Practice Address - Phone:765-446-2814
Practice Address - Fax:765-447-2870
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2016-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002083B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100100720Medicaid
IN100100720Medicaid
T35142Medicare UPIN