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General NPI Number Information
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NPI Number | 1366766255
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Entity Type | Organization
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Legal Business Name | DR. AMANDA WEITZEN, O.D. ,LLC
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Dates
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Enumeration Date | 03/21/2010
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Last Update Date | 03/21/2010
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Provider Practice Location Address
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Address Line | 4131 SOUTHSIDE BLVD STE 201
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City | JACKSONVILLE
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State | FL
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Zip | 32216-5478
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Country | US
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Telephone | 904-997-2018
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Fax | 904-997-2033
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Provider Business Mailing Address
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Address Line | 4131 SOUTHSIDE BLVD STE 201
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City | JACKSONVILLE
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State | FL
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Zip | 32216-5478
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Country | US
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Telephone | 904-997-2018
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Fax | 904-997-2033
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Authorized Official
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Title or Position | OWNER
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Name | AMANDA BETH WEITZEN
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Credential | O.D.
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Telephone | 904-997-2018
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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 | OPC 4248
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License Number State | FL
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