1760486500 NPI number — JACK L HOSTETLER O.D.

Table of content: JACK L HOSTETLER O.D. (NPI 1760486500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760486500 NPI number — JACK L HOSTETLER O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOSTETLER
Provider First Name:
JACK
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760486500
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/21/2006
NPI Reactivation Date:
03/29/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2680 S VAL VISTA DR
Provider Second Line Business Mailing Address:
#111
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85295-2152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-807-0288
Provider Business Mailing Address Fax Number:
480-299-7199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2680 S VAL VISTA DR
Provider Second Line Business Practice Location Address:
#111
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85295-2152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-807-0288
Provider Business Practice Location Address Fax Number:
480-299-7199
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  349 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 860439395 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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