Healthcare Provider Details

I. General information

NPI: 1770551129
Provider Name (Legal Business Name): JOHN B WACHTER JR. OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9375 66TH STREET NORTH EYE ASSOCIATES OF PINELLAS
PINELLAS PARK FL
33782
US

IV. Provider business mailing address

9375 66TH STREET NORTH
PINELLAS PARK FL
33782
US

V. Phone/Fax

Practice location:
  • Phone: 727-541-4469
  • Fax: 727-546-9661
Mailing address:
  • Phone: 727-541-4469
  • Fax: 727-546-9661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP0002459
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: