Provider Demographics
NPI:1225190440
Name:WONCH, JASON (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:WONCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:STE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6803
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:150 NORTHSHORE BLVD
Practice Address - Street 2:2060
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70460-6809
Practice Address - Country:US
Practice Address - Phone:985-641-7722
Practice Address - Fax:985-641-7894
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA1361-495T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B299Medicare ID - Type UnspecifiedMEDICARE
LAU89727Medicare UPIN