Healthcare Provider Details

I. General information

NPI: 1285703348
Provider Name (Legal Business Name): JASON MARC HEAVEN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5653 BUFORD HWY NE
DORAVILLE GA
30340-1200
US

IV. Provider business mailing address

2874 MITCHELL CV NE
ATLANTA GA
30319-2696
US

V. Phone/Fax

Practice location:
  • Phone: 770-396-2969
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1780
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: