Provider Demographics
NPI:1174175749
Name:JIANG, GUOMIN (OD)
Entity type:Individual
Prefix:
First Name:GUOMIN
Middle Name:
Last Name:JIANG
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 1:4940 HAZELWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-1270
Mailing Address - Country:US
Mailing Address - Phone:502-368-3937
Mailing Address - Fax:
Practice Address - Street 1:4940 HAZELWOOD AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-1270
Practice Address - Country:US
Practice Address - Phone:502-368-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2159DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist