=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710727664
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSE NING OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2024
-----------------------------------------------------
Last Update Date | 05/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 723 3RD ST SW
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33880-3419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-297-5067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 PHILIPS LAKE COURT
-----------------------------------------------------
City | RICHMOND HILL
-----------------------------------------------------
State | ONTARIO
-----------------------------------------------------
Zip | L4E 0S8
-----------------------------------------------------
Country | CA
-----------------------------------------------------
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 | OPC6450
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------