MEDICARE: JASON KOWALLIS OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	8288486	UT
2	152WV0400X	Vision Therapy Optometrist	8288486	UT

General Provider Information

NPI Number	:	1942561311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON KOWALLIS OD

Provider Business Mailing Address
First Line	:	165 W 200 N
Second Line	:
City	:	ROOSEVELT
State	:	UT
Zip	:	84066-2834
Country	:	US
Telephone Number	:	435-722-5890
Fax Number	:

Provider Business Practice Location Address
First Line	:	165 W 200 N
Second Line	:
City	:	ROOSEVELT
State	:	UT
Zip	:	84066-2834
Country	:	US
Telephone Number	:	435-722-5890
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2012
Last Update Date	:	02/02/2017

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Directions to “ JASON KOWALLIS OD” Practice Location

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