=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326778978
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB MATTHEW PETRO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2022
-----------------------------------------------------
Last Update Date | 06/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2140 BLOOMINGDALE AVE
-----------------------------------------------------
City | VALRICO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33596-6210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-413-3323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4323 FAIRCOURT DR
-----------------------------------------------------
City | VALRICO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33596-7802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 6098
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------