Provider Demographics
NPI:1598730954
Name:GOERGEN, JEFFREY MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:GOERGEN
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 1:8 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC
Mailing Address - State:IA
Mailing Address - Zip Code:50022-2645
Mailing Address - Country:US
Mailing Address - Phone:712-243-2190
Mailing Address - Fax:712-243-7540
Practice Address - Street 1:1501 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-1936
Practice Address - Country:US
Practice Address - Phone:712-243-7540
Practice Address - Fax:712-243-7544
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02112152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0194811Medicaid
IA1175695Medicaid
IA0194811Medicaid
IA03798Medicare ID - Type Unspecified