Healthcare Provider Details

I. General information

NPI: 1083040547
Provider Name (Legal Business Name): JASON C. KOSCHMEDER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 EUBANK BLVD NE SUITE A-4
ALBUQUERQUE NM
87111-1759
US

IV. Provider business mailing address

8801 HORIZON BLVD NE SUITE 360
ALBUQUERQUE NM
87113-1533
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-4419
  • Fax: 505-298-0878
Mailing address:
  • Phone: 505-828-4923
  • Fax: 505-213-0103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number660
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: