Provider Demographics
NPI:1326198649
Name:MAHURIN, JENNIFER S (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:MAHURIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:S
Other - Last Name:KOHLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:840 BORGIA LN
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-7212
Mailing Address - Country:US
Mailing Address - Phone:314-921-4652
Mailing Address - Fax:
Practice Address - Street 1:1600 MID RIVERS MALL
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-4360
Practice Address - Country:US
Practice Address - Phone:636-397-1222
Practice Address - Fax:636-278-1688
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000174047152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1595023Medicare PIN
MOU85594Medicare UPIN