Healthcare Provider Details

I. General information

NPI: 1972111847
Provider Name (Legal Business Name): JHALEIL PHILLIPS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 HAMPTON POINT DR STE 3
SAINT AUGUSTINE FL
32092-3058
US

IV. Provider business mailing address

161 HAMPTON POINT DR STE 3
SAINT AUGUSTINE FL
32092-3058
US

V. Phone/Fax

Practice location:
  • Phone: 904-287-9137
  • Fax: 904-287-9057
Mailing address:
  • Phone: 904-287-9137
  • Fax: 904-287-9057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT003263
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC5992
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: