Provider Demographics
NPI:1356419550
Name:JENSEN, RICHARD BRUCE (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BRUCE
Last Name:JENSEN
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 1:414 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2848
Mailing Address - Country:US
Mailing Address - Phone:321-267-0231
Mailing Address - Fax:321-267-0234
Practice Address - Street 1:414 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2848
Practice Address - Country:US
Practice Address - Phone:321-267-0231
Practice Address - Fax:321-267-0234
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2010-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1228152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T85185Medicare UPIN
FL19076Medicare ID - Type Unspecified