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General NPI Number Information
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NPI Number | 1225468473
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Entity Type | Organization
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Legal Business Name | DR. JASON IDICULLA O.D. PA
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Dates
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Enumeration Date | 11/24/2013
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Last Update Date | 11/24/2013
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Provider Practice Location Address
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Address Line | 3271 SOUTHWEST FWY SUITE A
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City | HOUSTON
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State | TX
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Zip | 77027-7503
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Country | US
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Telephone | 954-907-4966
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Fax |
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Provider Business Mailing Address
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Address Line | 2222 SMITH ST APT. 434
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City | HOUSTON
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State | TX
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Zip | 77002-8735
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. JASON IDICULLA
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Credential | O.D.
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Telephone | 954-907-4966
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 8235TG
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License Number State | TX
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