Provider Demographics
NPI:1407830730
Name:CHANG, JEWELL RENEE (OD)
Entity type:Individual
Prefix:DR
First Name:JEWELL
Middle Name:RENEE
Last Name:CHANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3201 NE SKYLINE DR
Mailing Address - Street 2:STE 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 STE D
Practice Address - Street 2:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2950152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20621Medicare PIN