MEDICARE: GREGORY PAUL JELLENEK 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	0618000342	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679505226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY PAUL JELLENEK O.D.

Provider Business Mailing Address
First Line	:	5251-18 JOHN TYLER HWY.
Second Line	:	#353
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23185-8808
Country	:	US
Telephone Number	:	757-963-1863
Fax Number	:	757-963-1881

Provider Business Practice Location Address
First Line	:	BLDG. 1527
Second Line	:
City	:	FT. EUSTIS
State	:	VA
Zip	:	23604-1618
Country	:	US
Telephone Number	:	757-887-3627
Fax Number	:	757-887-0403

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	05/23/2011

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