Provider Demographics
NPI:1184841553
Name:JEO, TINA (OD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:JEO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:JOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:10042 NE MASON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3511
Mailing Address - Country:US
Mailing Address - Phone:503-460-0030
Mailing Address - Fax:
Practice Address - Street 1:36775 HIGHWAY 26
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-7211
Practice Address - Country:US
Practice Address - Phone:503-668-7931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2009-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2616AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU90504Medicare UPIN
ORR113328Medicare ID - Type Unspecified