Provider Demographics
NPI:1174622245
Name:HILLMER, JED DUNHAM (OD)
Entity type:Individual
Prefix:
First Name:JED
Middle Name:DUNHAM
Last Name:HILLMER
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 1:101 10TH ST N
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4600
Mailing Address - Country:US
Mailing Address - Phone:701-239-9771
Mailing Address - Fax:701-293-0944
Practice Address - Street 1:101 10TH ST N
Practice Address - Street 2:SUITE 120
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4600
Practice Address - Country:US
Practice Address - Phone:701-239-9771
Practice Address - Fax:701-293-0944
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2011-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3051152W00000X
ND670152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V10534Medicare UPIN