Provider Demographics
NPI:1114278447
Name:BESECKER, JASON R (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:BESECKER
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 1:1130 E FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1813
Mailing Address - Country:US
Mailing Address - Phone:208-490-8823
Mailing Address - Fax:208-490-8525
Practice Address - Street 1:1130 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1813
Practice Address - Country:US
Practice Address - Phone:208-490-8823
Practice Address - Fax:208-490-8525
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4943152W00000X
IDODP-100254152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist