Healthcare Provider Details

I. General information

NPI: 1740621424
Provider Name (Legal Business Name): KATIE JO SIDER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE JO TEMPAUGH O.D.

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 07/21/2022
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6881 S YOSEMITE ST
CENTENNIAL CO
80112-1406
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 303-393-8378
  • Fax: 720-872-4902
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.003297
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG002820
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: