MEDICARE: LODO OPTICAL

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	332H00000X	Eyewear Supplier	07-70541-0000	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CO4853	OTHER	CO	EYEMED

General Provider Information

NPI Number	:	1174655997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LODO OPTICAL

Provider Business Mailing Address
First Line	:	1435 WAZEE ST STE 101
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80202-1491
Country	:	US
Telephone Number	:	303-299-9473
Fax Number	:	303-299-9472

Provider Business Practice Location Address
First Line	:	1435 WAZEE ST STE 101
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80202-1491
Country	:	US
Telephone Number	:	303-299-9473
Fax Number	:	303-299-9472

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RONALD ERIC WISE
Credential	:	M.D.
Telephone Number	:	303-299-9473

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	08/22/2020

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Directions to “LODO OPTICAL ” Practice Location

Language	Start Address	Practice Location

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