Provider Demographics
NPI:1730369232
Name:WEITZEN, JEROME
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:WEITZEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 N LAURA ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-3501
Mailing Address - Country:US
Mailing Address - Phone:904-353-3163
Mailing Address - Fax:904-355-1813
Practice Address - Street 1:213 N LAURA ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-3501
Practice Address - Country:US
Practice Address - Phone:904-353-3163
Practice Address - Fax:904-355-1813
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T93753Medicare UPIN
19784Medicare PIN