Provider Demographics
NPI:1194386367
Name:JUAREZ, JONATHAN AVERY (OD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:AVERY
Last Name:JUAREZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8457
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75404-8457
Mailing Address - Country:US
Mailing Address - Phone:903-454-1886
Mailing Address - Fax:903-455-3055
Practice Address - Street 1:4501 JOE RAMSEY BLVD E STE 110
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-7838
Practice Address - Country:US
Practice Address - Phone:903-454-1886
Practice Address - Fax:903-455-3055
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9739T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist