Healthcare Provider Details

I. General information

NPI: 1962497180
Provider Name (Legal Business Name): THOMAS WAYNE JASPER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7025 HOWDERSHELL RD
HAZELWOOD MO
63042-3811
US

IV. Provider business mailing address

2951 ARLMONT DR
SAINT LOUIS MO
63121-4618
US

V. Phone/Fax

Practice location:
  • Phone: 314-731-1117
  • Fax:
Mailing address:
  • Phone: 314-385-1142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02794
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: