Healthcare Provider Details

I. General information

NPI: 1861922601
Provider Name (Legal Business Name): JASON PORTER MERRELL OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 S SIGNAL BUTTE RD
MESA AZ
85209-1482
US

IV. Provider business mailing address

1661 E LUNA BLANCA WAY
SAN TAN VALLEY AZ
85140-8466
US

V. Phone/Fax

Practice location:
  • Phone: 480-358-9737
  • Fax:
Mailing address:
  • Phone: 208-390-0826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002328
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100409
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: