MEDICARE: DR. JACALYN RENEE ELY O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	TA0781	MD

General Provider Information

NPI Number	:	1356369011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACALYN RENEE ELY O.D.

Provider Business Mailing Address
First Line	:	7534 BROADCLOTH WAY
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21046-2446
Country	:	US
Telephone Number	:	410-381-5412
Fax Number	:	301-854-3297

Provider Business Practice Location Address
First Line	:	3933 FERRARA DR
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20906-4709
Country	:	US
Telephone Number	:	301-946-2550
Fax Number	:	301-946-2551

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	07/08/2007

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