Provider Demographics
NPI:1295769644
Name:KOENEN, JEFFREY LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LYNN
Last Name:KOENEN
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 1:700 LOCUST ST STE 302
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-3735
Mailing Address - Country:US
Mailing Address - Phone:515-244-7393
Mailing Address - Fax:515-244-2343
Practice Address - Street 1:700 LOCUST ST STE 302
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-3735
Practice Address - Country:US
Practice Address - Phone:515-244-7393
Practice Address - Fax:515-244-2343
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02072152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAU63058Medicare UPIN
IA55525Medicare ID - Type Unspecified