Healthcare Provider Details

I. General information

NPI: 1063233179
Provider Name (Legal Business Name): JAYSON PAUL FERD BURDEN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 N ANTHONY BLVD STE 46805
FORT WAYNE IN
46805-2283
US

IV. Provider business mailing address

3409 N ANTHONY BLVD STE 46805
FORT WAYNE IN
46805-2283
US

V. Phone/Fax

Practice location:
  • Phone: 260-484-2691
  • Fax:
Mailing address:
  • Phone: 260-484-2691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18004545A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: