Basic Information
| Provider Information | |||||||||
| NPI: | 1568497576 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UNGER | ||||||||
| FirstName: | JEFFREY | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512419700 | ||||||||
| FaxNumber: | 6512419896 | ||||||||
| Practice Location | |||||||||
| Address1: | 5565 BLAINE AVE | ||||||||
| Address2: | |||||||||
| City: | INVER GROVE HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512419400 | ||||||||
| FaxNumber: | 6514508066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2218 | MN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 510225100 | 05 | MN | MEDICAID |