Healthcare Provider Details

I. General information

NPI: 1033109483
Provider Name (Legal Business Name): EDWIN JEUNG O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 S 88TH ST STE 109
LOUISVILLE CO
80027-9418
US

IV. Provider business mailing address

1044 S 88TH ST STE 109
LOUISVILLE CO
80027-9418
US

V. Phone/Fax

Practice location:
  • Phone: 303-666-0104
  • Fax: 303-666-6844
Mailing address:
  • Phone: 303-666-0104
  • Fax: 303-666-6844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1094
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: