Provider Demographics
NPI:1093750424
Name:DEMOSS, JEAN LOUISE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:LOUISE
Last Name:DEMOSS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4875 WARD ROAD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033
Mailing Address - Country:US
Mailing Address - Phone:303-456-9456
Mailing Address - Fax:303-463-7560
Practice Address - Street 1:4875 WARD ROAD
Practice Address - Street 2:SUITE 600
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033
Practice Address - Country:US
Practice Address - Phone:303-456-9456
Practice Address - Fax:303-463-7560
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0002106152WP0200X
CO2106152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10851356Medicaid
CO10851356Medicaid
U75697Medicare UPIN
CO475148Medicare ID - Type Unspecified