Provider Demographics
NPI:1114215464
Name:FEDEL, CHERYL BAKER (OD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:BAKER
Last Name:FEDEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1001 E BRIDGE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-2275
Mailing Address - Country:US
Mailing Address - Phone:303-659-3036
Mailing Address - Fax:303-359-0053
Practice Address - Street 1:1001 E BRIDGE ST STE A
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-2276
Practice Address - Country:US
Practice Address - Phone:303-659-3036
Practice Address - Fax:303-659-0053
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2051528152W00000X
CO2839152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO85324001Medicaid
12263171OtherCAQH PROVIDER ID