Provider Demographics
NPI:1639433840
Name:BECKER, JASON (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:BECKER
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 1:3051 W CHANUTE PASS
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-3455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9250 N 3RD ST
Practice Address - Street 2:SUITE 3030
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2437
Practice Address - Country:US
Practice Address - Phone:602-944-3347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1859152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ162792Medicare PIN
AZZ162074Medicare PIN