MEDICARE: P JOE JITTAWAIT 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	1569	KS

General Provider Information

NPI Number	:	1992770564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	P JOE JITTAWAIT OD

Provider Business Mailing Address
First Line	:	1851 N WEBB RD
Second Line	:	ATTN FLR2
City	:	WICHITA
State	:	KS
Zip	:	67206-3413
Country	:	US
Telephone Number	:	316-636-2010
Fax Number	:	316-858-3830

Provider Business Practice Location Address
First Line	:	1851 N WEBB RD
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67206-3413
Country	:	US
Telephone Number	:	316-636-2010
Fax Number	:	316-858-3830

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

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	02/26/2008

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Directions to “ P JOE JITTAWAIT OD” Practice Location

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