Healthcare Provider Details

I. General information

NPI: 1609968684
Provider Name (Legal Business Name): JASON WONCH OD AND ASSOCIATES A P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 01/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 W PRIEN LAKE RD SUITE G05A
LAKE CHARLES LA
70601-8453
US

IV. Provider business mailing address

PO BOX 849759
DALLAS TX
75284-9759
US

V. Phone/Fax

Practice location:
  • Phone: 337-474-3395
  • Fax: 337-474-3397
Mailing address:
  • Phone: 210-524-6663
  • Fax: 210-524-6587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: JASON WONCH
Title or Position: OWNER
Credential: O.D.
Phone: 985-641-8866