MEDICARE: FORT LUPTON VISION CENTER PC

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	152W00000X	Optometrist	2357	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DP2823	OTHER	CO	RAILROAD MEDICARE GROUP PTAN

General Provider Information

NPI Number	:	1558544833
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT LUPTON VISION CENTER PC

Provider Business Mailing Address
First Line	:	301 DENVER AVE
Second Line	:
City	:	FORT LUPTON
State	:	CO
Zip	:	80621-1821
Country	:	US
Telephone Number	:	303-857-6550
Fax Number	:	303-857-6596

Provider Business Practice Location Address
First Line	:	301 DENVER AVE
Second Line	:
City	:	FORT LUPTON
State	:	CO
Zip	:	80621-1821
Country	:	US
Telephone Number	:	303-857-6550
Fax Number	:	303-857-6596

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAVID A SIMONSON
Credential	:	OD
Telephone Number	:	303-857-6550

Provider Enumeration Date	:	12/10/2007
Last Update Date	:	05/19/2023

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