Provider Demographics
NPI:1144259250
Name:GREGORY P. JELLENEK, OD & ASSOCIATES, PC
Entity type:Organization
Organization Name:GREGORY P. JELLENEK, OD & ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:P
Authorized Official - Last Name:JELLENEK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:757-963-1863
Mailing Address - Street 1:PO BOX 9439
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-9439
Mailing Address - Country:US
Mailing Address - Phone:757-963-1863
Mailing Address - Fax:757-465-1909
Practice Address - Street 1:12401 JEFFERSON AVE STE 1
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4311
Practice Address - Country:US
Practice Address - Phone:757-877-0388
Practice Address - Fax:757-833-7229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C06707Medicare ID - Type Unspecified