Provider Demographics
NPI:1285703348
Name:HEAVEN, JASON MARC (OD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MARC
Last Name:HEAVEN
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 1:2874 MITCHELL CV NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-2696
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5653 BUFORD HWY NE
Practice Address - Street 2:
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30340-1200
Practice Address - Country:US
Practice Address - Phone:770-396-2969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1780152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I415799Medicare PIN
GAU85880Medicare UPIN