Healthcare Provider Details

I. General information

NPI: 1053904672
Provider Name (Legal Business Name): JARED DAVID PETERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2021
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 HAHNS PEAK DR STE 180
LOVELAND CO
80538-8712
US

IV. Provider business mailing address

DEPARTMENT OF OPHTHALMOLOGY MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 303-772-3300
  • Fax: 303-682-3380
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD224449
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: