Provider Demographics
NPI:1578557294
Name:GONNASON, JEFFREY ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALLEN
Last Name:GONNASON
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 1:2211 E NORTHERN LIGHTS BLVD
Mailing Address - Street 2:STE 202
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4103
Mailing Address - Country:US
Mailing Address - Phone:907-276-2080
Mailing Address - Fax:907-276-2081
Practice Address - Street 1:2211 E NORTHERN LIGHTS BLVD
Practice Address - Street 2:STE 202
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4103
Practice Address - Country:US
Practice Address - Phone:907-276-2080
Practice Address - Fax:907-276-2081
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKOPT T 75152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOP0075Medicaid
AK0000JHDZDMedicare ID - Type Unspecified