Basic Information
Provider Information
NPI: 1093816167
EntityType: 2
ReplacementNPI:  
OrganizationName: JASON WONCH OD AND ASSOCIATES APC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: VISIONWORKS
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 849759
Address2:  
City: DALLAS
State: TX
PostalCode: 752849759
CountryCode: US
TelephoneNumber: 2105246663
FaxNumber: 2105246587
Practice Location
Address1: 5953 WEST PARK AVENUE
Address2:  
City: HOUMA
State: LA
PostalCode: 70364
CountryCode: US
TelephoneNumber: 9858680699
FaxNumber: 9858680535
Other Information
ProviderEnumerationDate: 09/25/2006
LastUpdateDate: 01/04/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: WONCH
AuthorizedOfficialFirstName: JASON
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 9856418866
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: OD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
332H00000X  Y SuppliersEyewear Supplier (Equipment, not the service) 

No ID Information.


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