Provider Demographics
NPI:1427139278
Name:SARMIENTO, JENNIFER DAWN (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:DAWN
Last Name:SARMIENTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 N MONTEZUMA ST
Mailing Address - Street 2:STE108A
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-3020
Mailing Address - Country:US
Mailing Address - Phone:928-445-3808
Mailing Address - Fax:928-778-3559
Practice Address - Street 1:377 N MONTEZUMA ST
Practice Address - Street 2:STE108A
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-3020
Practice Address - Country:US
Practice Address - Phone:928-445-3808
Practice Address - Fax:928-778-3559
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ01235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0904090OtherBC/BS
AZ813354Medicaid
AZZ165194Medicare PIN
AZU82521Medicare UPIN
AZ813354Medicaid