Provider Demographics
NPI:1811974900
Name:PHILLIPS, JEFFREY DEAN (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DEAN
Last Name:PHILLIPS
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 1:1903 TYRONE BLVD.
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710
Mailing Address - Country:US
Mailing Address - Phone:727-345-4035
Mailing Address - Fax:727-384-3112
Practice Address - Street 1:1903 TYRONE BLVD 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
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078676400Medicaid
FL4557700001Medicare NSC
T85263Medicare UPIN
19724Medicare ID - Type Unspecified