Healthcare Provider Details

I. General information

NPI: 1477531432
Provider Name (Legal Business Name): JAY JUSTIN OLDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 E FLETCHER AVE STE D
TAMPA FL
33613-4905
US

IV. Provider business mailing address

4444 E FLETCHER AVE STE D
TAMPA FL
33613-4905
US

V. Phone/Fax

Practice location:
  • Phone: 813-971-3846
  • Fax: 813-977-2611
Mailing address:
  • Phone: 813-971-3846
  • Fax: 813-977-2611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME21356
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberME21356
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: