Healthcare Provider Details

I. General information

NPI: 1811031859
Provider Name (Legal Business Name): JERRY R. PEDERSON, O.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6650 S VINE ST SUITE 160
CENTENNIAL CO
80121-2735
US

IV. Provider business mailing address

6650 S VINE ST SUITE 160
CENTENNIAL CO
80121-2735
US

V. Phone/Fax

Practice location:
  • Phone: 303-798-5533
  • Fax: 303-798-2800
Mailing address:
  • Phone: 303-798-5533
  • Fax: 303-798-2800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number724
License Number StateCO

VIII. Authorized Official

Name: DR. JERRY RAY PEDERSON
Title or Position: OWNER
Credential: O.D.
Phone: 303-798-5533