Provider Demographics
NPI:1689751166
Name:WALLACE, JASON (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:WALLACE
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 1:1921 VARICK WAY
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-2410
Mailing Address - Country:US
Mailing Address - Phone:407-637-9621
Mailing Address - Fax:
Practice Address - Street 1:502 CELEBRATION AVE
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-4687
Practice Address - Country:US
Practice Address - Phone:407-566-8505
Practice Address - Fax:407-566-8253
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4182152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist