Provider Demographics
NPI:1346288339
Name:JEROME WEITZEN OD PA
Entity Type:Organization
Organization Name:JEROME WEITZEN OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:WEITZEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-353-3163
Mailing Address - Street 1:213 N LAURA ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-3501
Mailing Address - Country:US
Mailing Address - Phone:904-353-3163
Mailing Address - Fax:904-355-1813
Practice Address - Street 1:213 N LAURA ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-3501
Practice Address - Country:US
Practice Address - Phone:904-353-3163
Practice Address - Fax:904-355-1813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084160900Medicaid
T93753Medicare UPIN
FL19784Medicare PIN
FL0554640001Medicare NSC