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General NPI Number Information
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NPI Number | 1609145507
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Entity Type | Organization
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Legal Business Name | JACK N SPERRY JR O.D. PA
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Dates
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Enumeration Date | 12/21/2011
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Last Update Date | 11/05/2012
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Provider Practice Location Address
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Address Line | 720 LAKE DORA DR
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City | TAVARES
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State | FL
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Zip | 32778-3314
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Country | US
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Telephone | 352-551-5612
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Fax |
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Provider Business Mailing Address
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Address Line | 720 LAKE DORA DR
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City | TAVARES
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State | FL
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Zip | 32778-3314
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Country | US
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Telephone | 352-551-5612
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JACK N SPERRY JR.
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Credential | O. D.
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Telephone | 352-551-5612
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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 | OPC2330
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License Number State | FL
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