Provider Demographics
NPI:1548364946
Name:BEGAL, JEROME V (OD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:V
Last Name:BEGAL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213
Mailing Address - Country:US
Mailing Address - Phone:210-524-6803
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:355 S WADSWORTH BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226
Practice Address - Country:US
Practice Address - Phone:720-962-6906
Practice Address - Fax:720-962-6972
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO891152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU32615Medicare UPIN