Healthcare Provider Details

I. General information

NPI: 1053731679
Provider Name (Legal Business Name): JASON HOLMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 N ORANGE BLOSSOM TRL
ORLANDO FL
32805-1612
US

IV. Provider business mailing address

232 N ORANGE BLOSSOM TRL
ORLANDO FL
32805-1612
US

V. Phone/Fax

Practice location:
  • Phone: 407-428-5751
  • Fax: 407-428-6204
Mailing address:
  • Phone: 407-428-5751
  • Fax: 407-428-6204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDO 6465
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: