Provider Demographics
NPI:1164400875
Name:JENSEN, DAVID WARREN (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WARREN
Last Name:JENSEN
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 1:640 HIGHWAY 1 W
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52246-4218
Mailing Address - Country:US
Mailing Address - Phone:319-338-6700
Mailing Address - Fax:
Practice Address - Street 1:640 HIGHWAY 1 W
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52246-4218
Practice Address - Country:US
Practice Address - Phone:319-338-6700
Practice Address - Fax:319-887-1101
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1713152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1713OtherLICENSE NUMBER
IA1713OtherLICENSE NUMBER
IA0209490001Medicare NSC