Provider Demographics
NPI:1073551206
Name:IANNARELLI, JASON EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:EDWARD
Last Name:IANNARELLI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 HAND AVENUE
Mailing Address - Street 2:UNIT N
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174
Mailing Address - Country:US
Mailing Address - Phone:386-872-3111
Mailing Address - Fax:386-872-3190
Practice Address - Street 1:1400 HAND AVENUE
Practice Address - Street 2:UNIT N
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-872-3111
Practice Address - Fax:386-872-3190
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3902152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV03028Medicare UPIN
FLU4010Medicare PIN