Provider Demographics
NPI:1083040547
Name:KOSCHMEDER, JASON C (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:C
Last Name:KOSCHMEDER
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:8801 HORIZON BLVD NE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1533
Mailing Address - Country:US
Mailing Address - Phone:505-828-4923
Mailing Address - Fax:505-213-0103
Practice Address - Street 1:5200 EUBANK BLVD NE
Practice Address - Street 2:SUITE A-4
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1759
Practice Address - Country:US
Practice Address - Phone:505-298-4419
Practice Address - Fax:505-298-0878
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2014-12-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM660152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78880386Medicaid
NM345981YTQZMedicare PIN