Healthcare Provider Details

I. General information

NPI: 1699730440
Provider Name (Legal Business Name): JIRO KAMEOKA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6310 S US HIGHWAY 85-87
FOUNTAIN CO
80817-1006
US

IV. Provider business mailing address

727 BEAR PAW LN S
COLORADO SPRINGS CO
80906-3220
US

V. Phone/Fax

Practice location:
  • Phone: 719-390-8649
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-2215
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT-2215
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: