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General NPI Number Information
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NPI Number | 1285703348
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Entity Type | Individual
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Provider Name | JASON MARC HEAVEN O.D.
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Gender | Male
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Dates
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Enumeration Date | 11/06/2006
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Last Update Date | 04/29/2010
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Provider Practice Location Address
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Address Line | 5653 BUFORD HWY NE
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City | DORAVILLE
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State | GA
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Zip | 30340-1200
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Country | US
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Telephone | 770-396-2969
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Fax |
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Provider Business Mailing Address
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Address Line | 2874 MITCHELL CV NE
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City | ATLANTA
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State | GA
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Zip | 30319-2696
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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 |
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Name |
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Credential |
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Telephone |
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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 | 1780
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License Number State | GA
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