MEDICARE: VIVECA JANEL VERHAGEN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2409	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1508	OTHER	FL	STATE LICENSE NUMBER
2	2409	OTHER	CO	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1528048352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIVECA JANEL VERHAGEN O.D.

Provider Business Mailing Address
First Line	:	5026 E HAMPDEN AVE
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80222-7329
Country	:	US
Telephone Number	:	303-756-5900
Fax Number	:	303-756-5902

Provider Business Practice Location Address
First Line	:	5026 E HAMPDEN AVE
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80222-7329
Country	:	US
Telephone Number	:	303-756-5900
Fax Number	:	303-756-5902

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2006
Last Update Date	:	07/09/2007

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