=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386789907
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK L EWAN O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 LAFAYETTE ST SUITE E
-----------------------------------------------------
City | LONDON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43140-9069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-852-4903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1930 JERVIS RD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43221-2772
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-852-4903
-----------------------------------------------------
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 | 3600 T49
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------