Provider Demographics
NPI:1336142793
Name:OWENS, JONATHAN DANIEL (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DANIEL
Last Name:OWENS
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:PO BOX 544
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632
Mailing Address - Country:US
Mailing Address - Phone:970-926-8474
Mailing Address - Fax:970-926-3634
Practice Address - Street 1:1140 EDWARDS VILLAGE BLVD.
Practice Address - Street 2:B-206
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:970-926-8474
Practice Address - Fax:970-926-3634
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2148152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO23973081Medicaid
COU81490Medicare UPIN
COCO303738Medicare PIN