Provider Demographics
NPI:1033109483
Name:JEUNG, EDWIN (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:
Last Name:JEUNG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 S 88TH ST STE 109
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-9418
Mailing Address - Country:US
Mailing Address - Phone:303-666-0104
Mailing Address - Fax:303-666-6844
Practice Address - Street 1:1044 S 88TH ST STE 109
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9418
Practice Address - Country:US
Practice Address - Phone:303-666-0104
Practice Address - Fax:303-666-6844
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1094152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08010944Medicaid
CO1094OtherCOLORADO LIC. #
COC40373OtherMEDICARE ID
COT60833Medicare UPIN
CO1114030001Medicare NSC