Provider Demographics
NPI:1740587633
Name:JEPSON, MAX (OD)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:
Last Name:JEPSON
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 68
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-0068
Mailing Address - Country:US
Mailing Address - Phone:605-224-8666
Mailing Address - Fax:605-224-8458
Practice Address - Street 1:430 W SIOUX AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-2445
Practice Address - Country:US
Practice Address - Phone:605-224-8666
Practice Address - Fax:605-224-8458
Is Sole Proprietor?:No
Enumeration Date:2011-02-11
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD688152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1740587633Medicaid