Provider Demographics
NPI:1215922174
Name:ST JEAN, REBECCA V (OD)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:V
Last Name:ST JEAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4030 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1510
Mailing Address - Country:US
Mailing Address - Phone:304-766-2220
Mailing Address - Fax:304-766-0824
Practice Address - Street 1:4030 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1510
Practice Address - Country:US
Practice Address - Phone:304-766-2220
Practice Address - Fax:304-766-0824
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV989OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7230192OtherAETNA
132743OtherCARELINK
U68856Medicare UPIN
WVST4048011Medicare ID - Type Unspecified
WVSP00611Medicare PIN
WV5056190001Medicare NSC