Provider Demographics
NPI:1841314945
Name:JEWELL R. CHANG OD PA
Entity type:Organization
Organization Name:JEWELL R. CHANG OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEWELL
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:772-334-4264
Mailing Address - Street 1:3201 NE SKYLINE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-3912
Mailing Address - Country:US
Mailing Address - Phone:772-334-4264
Mailing Address - Fax:772-334-4265
Practice Address - Street 1:3201 NE SKYLINE DR
Practice Address - Street 2:SUITE D
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-3912
Practice Address - Country:US
Practice Address - Phone:772-334-4264
Practice Address - Fax:772-334-4265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2950152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
20621OtherBLUE CROSS BLUE SHIELD
5624127OtherAETNA
20621OtherBLUE CROSS BLUE SHIELD
=========OtherPREFERRED BENEFIT
=========OtherCIGNA
5624127OtherAETNA
=========OtherBEECH STREET
=========OtherUNITED HEALTH CARE
FLPENDINGMedicare PIN