Basic Information
| Provider Information | |||||||||
| NPI: | 1760121206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEISS | ||||||||
| FirstName: | JAKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1129 WOODROW ST | ||||||||
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| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292051224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152909187 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1920 PICKENS ST | ||||||||
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| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037793070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2022 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT.2348 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.