Healthcare Provider Details

I. General information

NPI: 1689507329
Provider Name (Legal Business Name): JERE MICAH WEST LDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MICAH WEST LDO

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 MAIN ST
CHIPLEY FL
32428-5992
US

IV. Provider business mailing address

1621 MAIN ST
CHIPLEY FL
32428-5992
US

V. Phone/Fax

Practice location:
  • Phone: 850-638-3214
  • Fax: 850-638-7797
Mailing address:
  • Phone: 850-638-3214
  • Fax: 850-638-7797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDO8439
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: