Active NPI
Jay Wilfred Mauck, OD
- Optometrist
- The Dalles, OR
National Provider Identifier
1184608325
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 12417
- Practice address
- 415 Washington St
The Dalles, OR 97058-2215 - Phone
- (541) 296-2911
- Fax
- (541) 296-2224
- NPI assigned
- Dec 1, 2005
- Last updated
- Nov 16, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 12417 | OR | Primary |
Addresses
Primary practice location
415 Washington St
The Dalles, OR 97058-2215
Mailing address
PO Box 883
The Dalles, OR 97058-0883
Phone (541) 296-2911
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 236026 | Medicaid | OR |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 12417 | OR | MD | Optometrist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| DRS Mauck & Perkins Opt PC | Optometrist | Past | Accepting new patients |
| Cea Acquisition LLC | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1133395200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1195171200000",
"number": "1184608325",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 883",
"city": "THE DALLES",
"state": "OR",
"postal_code": "970580883",
"telephone_number": "541-296-2911",
"fax_number": "541-296-2224"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "415 WASHINGTON ST",
"city": "THE DALLES",
"state": "OR",
"postal_code": "970582215",
"telephone_number": "541-296-2911",
"fax_number": "541-296-2224"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MAUCK",
"first_name": "JAY",
"middle_name": "WILFRED",
"credential": "OD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-12-01",
"last_updated": "2007-11-16",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "OR",
"license": "12417",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "236026",
"state": "OR"
}
],
"endpoints": [],
"other_names": []
}Other providers in The Dalles, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 16, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.