Provider Demographics
NPI:1366766255
Name:DR. AMANDA WEITZEN, O.D. ,LLC
Entity type:Organization
Organization Name:DR. AMANDA WEITZEN, O.D. ,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:WEITZEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-997-2018
Mailing Address - Street 1:4131 SOUTHSIDE BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5478
Mailing Address - Country:US
Mailing Address - Phone:904-997-2018
Mailing Address - Fax:904-997-2033
Practice Address - Street 1:4131 SOUTHSIDE BLVD
Practice Address - Street 2:STE 201
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5478
Practice Address - Country:US
Practice Address - Phone:904-997-2018
Practice Address - Fax:904-997-2033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-21
Last Update Date:2010-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4248152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty