Provider Demographics
NPI:1356406730
Name:HEDGES, JACOB (OD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HEDGES
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 1:11103 WEST AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6803
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:7700 W ARROWHEAD TOWNE CTR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8616
Practice Address - Country:US
Practice Address - Phone:210-524-6803
Practice Address - Fax:210-524-6587
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1516152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ162076Medicare PIN
AZZ163918Medicare PIN
AZZ163921Medicare PIN
AZZ163916Medicare PIN
AZZ162074Medicare PIN
AZZ162077Medicare PIN
AZZ162078Medicare PIN
AZZ163919Medicare PIN
AZZ163920Medicare PIN
AZZ162075Medicare PIN
AZZ163917Medicare PIN
AZZ162079Medicare PIN