Provider Demographics
NPI:1760486500
Name:HOSTETLER, JACK L (OD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:HOSTETLER
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 1:2680 S VAL VISTA DR
Mailing Address - Street 2:#111
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-2152
Mailing Address - Country:US
Mailing Address - Phone:480-807-0288
Mailing Address - Fax:480-299-7199
Practice Address - Street 1:2680 S VAL VISTA DR
Practice Address - Street 2:#111
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-2152
Practice Address - Country:US
Practice Address - Phone:480-807-0288
Practice Address - Fax:480-299-7199
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2008-06-25
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
AZ349152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860439395Medicaid
AZT41753Medicare UPIN