Provider Demographics
NPI:1043389505
Name:ENGLE, JON GLEN (OD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:GLEN
Last Name:ENGLE
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 1:295 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1833
Mailing Address - Country:US
Mailing Address - Phone:440-234-3800
Mailing Address - Fax:440-234-2318
Practice Address - Street 1:295 HIGH ST
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-1833
Practice Address - Country:US
Practice Address - Phone:440-234-3800
Practice Address - Fax:440-234-2318
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5548152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist