Provider Demographics
NPI:1467511105
Name:STREET, JASON TRAVERS (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:TRAVERS
Last Name:STREET
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 1:102 WESTMOUNT DRIVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-0829
Mailing Address - Country:US
Mailing Address - Phone:573-756-3170
Mailing Address - Fax:573-756-0173
Practice Address - Street 1:102 WESTMOUNT DRIVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-0829
Practice Address - Country:US
Practice Address - Phone:573-756-3170
Practice Address - Fax:573-756-0173
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000160791152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO315093518Medicaid
U81285Medicare UPIN
MO315093518Medicaid