Provider Demographics
NPI:1396160479
Name:JARED HAGAN OPTOMETRY
Entity type:Organization
Organization Name:JARED HAGAN OPTOMETRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:858-876-7456
Mailing Address - Street 1:7007 FRIARS RD STE 667A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1148
Mailing Address - Country:US
Mailing Address - Phone:858-876-7456
Mailing Address - Fax:888-723-8436
Practice Address - Street 1:5929 MILDRED ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-1422
Practice Address - Country:US
Practice Address - Phone:858-876-7456
Practice Address - Fax:888-723-8436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT14385TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT14385TLGOtherCALIFORNIA OPTOMETRY LICENSE