Provider Demographics
NPI:1538127170
Name:JENSEN, DENMARK R (OD)
Entity Type:Individual
Prefix:
First Name:DENMARK
Middle Name:R
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 1:180 WEST GORDON AVE STE E1
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041
Mailing Address - Country:US
Mailing Address - Phone:801-546-2481
Mailing Address - Fax:801-546-2483
Practice Address - Street 1:180 WEST GORDON AVE STE E1
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041
Practice Address - Country:US
Practice Address - Phone:801-546-2481
Practice Address - Fax:801-546-2483
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5673488-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055082Medicare PIN
UTV00633Medicare UPIN