Provider Demographics
NPI:1285757591
Name:JENSEN, MICHAEL PETER (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PETER
Last Name:JENSEN
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 WILDWOOD EST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-5002
Mailing Address - Country:US
Mailing Address - Phone:518-561-8356
Mailing Address - Fax:
Practice Address - Street 1:450 MARGARET ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1755
Practice Address - Country:US
Practice Address - Phone:518-566-2020
Practice Address - Fax:518-561-5390
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4928156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01550430Medicaid