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General NPI Number Information
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NPI Number | 1861062176
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Entity Type | Individual
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Provider Name | JACOB MITTELSTAEDT OD
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Gender | Male
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Dates
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Enumeration Date | 06/29/2021
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Last Update Date | 03/13/2023
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Provider Practice Location Address
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Address Line | 119 PATTERSON RD
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City | HAINES CITY
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State | FL
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Zip | 33844-7803
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Country | US
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Telephone | 863-421-2700
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Fax | 863-421-7629
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Provider Business Mailing Address
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Address Line | 8614 WESTWOOD CENTER DR FL 9
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City | VIENNA
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State | VA
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Zip | 22182-2442
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Country | US
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Telephone | 703-847-8899
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Fax | 571-223-6780
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 0003685
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC6190
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License Number State | FL
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