Provider Demographics
NPI:1649362989
Name:JEFFREY D. PHILLIPS, O.D., P.A.
Entity type:Organization
Organization Name:JEFFREY D. PHILLIPS, O.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:727-345-4035
Mailing Address - Street 1:1903 TYRONE BOULEVARD N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-4841
Mailing Address - Country:US
Mailing Address - Phone:727-345-4035
Mailing Address - Fax:727-384-3112
Practice Address - Street 1:1903 TYRONE BOULEVARD N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-4841
Practice Address - Country:US
Practice Address - Phone:727-345-4035
Practice Address - Fax:727-384-3112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620359100Medicaid
FL620359100Medicaid
FL4557700001Medicare NSC