Provider Demographics
NPI:1922624147
Name:DRAVITZKI, JORDAN (OD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:DRAVITZKI
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:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:STROMSBURG
Mailing Address - State:NE
Mailing Address - Zip Code:68666-0082
Mailing Address - Country:US
Mailing Address - Phone:402-764-0457
Mailing Address - Fax:
Practice Address - Street 1:2201 W DOLARWAY RD
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-8228
Practice Address - Country:US
Practice Address - Phone:509-925-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61069395152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty