Basic Information
| Provider Information | |||||||||
| NPI: | 1720064579 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NITARDY | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | JOEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 FM 300 | ||||||||
| Address2: | |||||||||
| City: | LEVELLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 793366235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8068947842 | ||||||||
| FaxNumber: | 8068943378 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 SUNLAND PARK DRIVE | ||||||||
| Address2: | STE G1 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155851928 | ||||||||
| FaxNumber: | 9158339626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 6556T | TX | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.