Provider Demographics
NPI:1104418490
Name:JONES, ANGELICA (OD)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:JONES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ANGELICA
Other - Middle Name:SHANTA
Other - Last Name:MCINTYRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4633 HERMOSA RD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-6734
Mailing Address - Country:US
Mailing Address - Phone:601-818-1428
Mailing Address - Fax:
Practice Address - Street 1:778 BEAL PKWY NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-3042
Practice Address - Country:US
Practice Address - Phone:850-586-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5892152W00000X
ALSE68TAC09152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherN/A