Provider Demographics
NPI:1841235975
Name:SIBBLE, JASON D (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:D
Last Name:SIBBLE
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 1:12 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895-1057
Mailing Address - Country:US
Mailing Address - Phone:585-593-6041
Mailing Address - Fax:585-593-4919
Practice Address - Street 1:12 MARTIN ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-1057
Practice Address - Country:US
Practice Address - Phone:585-593-6041
Practice Address - Fax:585-593-4919
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT006401152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY115176CSOtherPREF CARE, PREF GOLD
NYU86175Medicare UPIN
565140BMedicare PIN
565140AMedicare PIN