Provider Demographics
NPI:1770508426
Name:JENSEN, GARY L
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:JENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:L
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:11 NW FIRST AVE
Mailing Address - Street 2:
Mailing Address - City:CHISHOLM
Mailing Address - State:MN
Mailing Address - Zip Code:55719-1811
Mailing Address - Country:US
Mailing Address - Phone:218-254-4393
Mailing Address - Fax:218-254-5471
Practice Address - Street 1:11 NW FIRST AVE
Practice Address - Street 2:
Practice Address - City:CHISHOLM
Practice Address - State:MN
Practice Address - Zip Code:55719-1811
Practice Address - Country:US
Practice Address - Phone:218-254-4393
Practice Address - Fax:218-254-5471
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1610152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2200981OtherMDMA2 MEDICA PIN
OD327JEOtherBCMA BCBS PIN
411260738OtherPABS CLARITY VISION PIN
OD327JEOtherFIRST FIRST PLAN PIN
01020509OtherBOIS PREFERRED ONE PIN
01020509OtherPRE00 UNITED HEALTH PIN
2200980OtherMCCS1 MEDICA PIN
OD327JEOtherANTHEM BCBS PIN
OD327JEOtherFIRSD FIRST PLAN DISP PIN
0150730001OtherADMINISTAR FEDERAL(DMERC), INC.
2100694OtherMDMA3 MEDICA PIN
2200980OtherMDMA1 MEDICA PIN
411260738OtherBCWP BCBS OF PENN PIN
OD327JEOtherBCMN BCBS PIN
524223100OtherMNMA MN MED ASSIST PIN
OD327JEOtherBCMAD BCBS PIN
OD327JEOtherCOM COMP CARE PIN
2200980OtherMCCS1 MEDICA PIN
T65653Medicare UPIN
OD327JEOtherBCMN BCBS PIN
01020509OtherPRE00 UNITED HEALTH PIN