Provider Demographics
NPI:1811140643
Name:HISCOX, JACOB WYLEY (OD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:WYLEY
Last Name:HISCOX
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8456 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-4010
Mailing Address - Country:US
Mailing Address - Phone:520-885-2052
Mailing Address - Fax:520-886-7488
Practice Address - Street 1:7402 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-1411
Practice Address - Country:US
Practice Address - Phone:520-885-2052
Practice Address - Fax:520-886-7488
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ1643152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist