Provider Demographics
NPI:1518135326
Name:VISION SOURCE OF EAST BROWARD LLC
Entity Type:Organization
Organization Name:VISION SOURCE OF EAST BROWARD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-771-9120
Mailing Address - Street 1:2419 E COMMERCIAL BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4042
Mailing Address - Country:US
Mailing Address - Phone:954-771-9120
Mailing Address - Fax:954-771-4883
Practice Address - Street 1:2419 E COMMERCIAL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308
Practice Address - Country:US
Practice Address - Phone:954-771-9120
Practice Address - Fax:954-771-4883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC951152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU82477Medicare UPIN
FLDS5706Medicare PIN
FLT83988Medicare UPIN
FLU24013Medicare UPIN
FLAJ879Medicare PIN