Basic Information
| Provider Information | |||||||||
| NPI: | 1861922601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERRELL | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | PORTER | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1661 E LUNA BLANCA WAY | ||||||||
| Address2: | |||||||||
| City: | SAN TAN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851408466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083900826 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1606 S SIGNAL BUTTE RD | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852091482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803589737 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2017 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT-002328 | AZ | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | ODP-100409 | ID | N | Eye and Vision Services Providers | Optometrist |
No ID Information.