Provider Demographics
NPI:1134400054
Name:DEAL, JUSTIN DANIEL (OD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DANIEL
Last Name:DEAL
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 1:1200 S HOVER ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-7902
Mailing Address - Country:US
Mailing Address - Phone:303-845-4215
Mailing Address - Fax:303-682-8181
Practice Address - Street 1:1200 S HOVER ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-7902
Practice Address - Country:US
Practice Address - Phone:303-845-4215
Practice Address - Fax:303-682-8181
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2875152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54686270Medicaid