Provider Demographics
NPI:1093149320
Name:FORNARA, JASON WESLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:WESLEY
Last Name:FORNARA
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 1:199 S CANDY LN
Mailing Address - Street 2:SUITE #2
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4183
Mailing Address - Country:US
Mailing Address - Phone:928-634-2883
Mailing Address - Fax:
Practice Address - Street 1:199 S CANDY LN
Practice Address - Street 2:SUITE #2
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4183
Practice Address - Country:US
Practice Address - Phone:928-634-2883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1943152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist