Provider Demographics
NPI:1699050849
Name:JASON WONCH OD AND ASSOCIATES APC
Entity type:Organization
Organization Name:JASON WONCH OD AND ASSOCIATES APC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:D
Authorized Official - Last Name:WONCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-524-6803
Mailing Address - Street 1:PO BOX 849759
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-9759
Mailing Address - Country:US
Mailing Address - Phone:210-524-6803
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:1133 SAINT VINCENT AVE
Practice Address - Street 2:BOX 34
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-4153
Practice Address - Country:US
Practice Address - Phone:318-227-8053
Practice Address - Fax:318-227-8054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier