Provider Demographics
NPI:1538224308
Name:FENEIS, JEAN M (OD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:FENEIS
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 1:5069 GLEN VIEW PL
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-2629
Mailing Address - Country:US
Mailing Address - Phone:619-479-0342
Mailing Address - Fax:
Practice Address - Street 1:555 SHOPS AT MISSION VIEJO
Practice Address - Street 2:STE 30 SHOPS AT MISSION VIEJO
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-364-4010
Practice Address - Fax:949-364-4001
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9840TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist