Healthcare Provider Details

I. General information

NPI: 1568745354
Provider Name (Legal Business Name): ASHLEY L COWART O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11512 LAKE MEAD AVE STE 534
JACKSONVILLE FL
32256-9680
US

IV. Provider business mailing address

11945 SAN JOSE BLVD STE 300
JACKSONVILLE FL
32223-1613
US

V. Phone/Fax

Practice location:
  • Phone: 904-564-2020
  • Fax: 904-518-3297
Mailing address:
  • Phone: 904-396-1725
  • Fax: 904-399-1717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC4610
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: