Provider Demographics
NPI:1710983861
Name:AMUNDSON, JILL M (OD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:AMUNDSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BARLEY LN
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-8442
Mailing Address - Country:US
Mailing Address - Phone:207-415-4709
Mailing Address - Fax:
Practice Address - Street 1:15 LOWELL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2748
Practice Address - Country:US
Practice Address - Phone:207-774-8277
Practice Address - Fax:207-699-5850
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT843152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME323720099Medicaid
MEU58795Medicare UPIN
MEMM9254Medicare ID - Type Unspecified