Healthcare Provider Details

I. General information

NPI: 1407842628
Provider Name (Legal Business Name): JON F PEDERSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6650 S VINE ST STE 160
CENTENNIAL CO
80121-2769
US

IV. Provider business mailing address

1410 S COLUMBINE ST
DENVER CO
80210-2419
US

V. Phone/Fax

Practice location:
  • Phone: 303-798-5533
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2468
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: