Basic Information
| Provider Information | |||||||||
| NPI: | 1295769008 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JASON WONCH, O.D. AND ASSOCIATES, A.P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | VISIONWORKS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 E HOUSTON ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782052255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105246803 | ||||||||
| FaxNumber: | 2105246587 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 WEST ESPLANADE BOULEVARD, | ||||||||
| Address2: | #208 | ||||||||
| City: | KENNER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044663613 | ||||||||
| FaxNumber: | 5044615354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | WONCH | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5044663613 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1448265 | 05 | LA | MEDICAID |