Provider Demographics
NPI:1043380066
Name:KOSTER, JENNIFER (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KOSTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KEENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4902 E KIRKLAND RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-6183
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8752 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6640
Practice Address - Country:US
Practice Address - Phone:480-991-6432
Practice Address - Fax:480-991-2143
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1477152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ105635Medicare ID - Type Unspecified
AZV06667Medicare UPIN