Provider Demographics
NPI:1124319066
Name:MCCANN, JESSE THOMAS (MD PHD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:THOMAS
Last Name:MCCANN
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 E VENICE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-9066
Mailing Address - Country:US
Mailing Address - Phone:941-480-2135
Mailing Address - Fax:941-484-2200
Practice Address - Street 1:1360 E VENICE AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-9066
Practice Address - Country:US
Practice Address - Phone:941-488-2020
Practice Address - Fax:941-484-2200
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME132807207W00000X, 207WX0107X
NY270516207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4PPP5OtherFLORIDA BLUE
FL021181600Medicaid