Healthcare Provider Details

I. General information

NPI: 1346155611
Provider Name (Legal Business Name): GRANGER RETINA CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2288 BANYAN HILL CT
FORT WAYNE IN
46814-9590
US

IV. Provider business mailing address

2288 BANYAN HILL CT
FORT WAYNE IN
46814-9590
US

V. Phone/Fax

Practice location:
  • Phone: 225-573-9954
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON MIN SO
Title or Position: PRESIDENT
Credential: MD
Phone: 225-573-9954