Provider Demographics
NPI:1124224589
Name:BARTON M PEDERSEN O.D. AN OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:BARTON M PEDERSEN O.D. AN OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BARTON
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-228-2020
Mailing Address - Street 1:56970 YUCCA TRL # S-101
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-3753
Mailing Address - Country:US
Mailing Address - Phone:760-228-2020
Mailing Address - Fax:760-369-2020
Practice Address - Street 1:56970 YUCCA TRL # S-101
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-3753
Practice Address - Country:US
Practice Address - Phone:760-228-2020
Practice Address - Fax:760-369-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT4600T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1134103484OtherDENNIS G. LOWMAN O.D.
CA1215911565OtherCHARLES J. BAUS, O.D.
CA1336123686OtherBARTON M. PEDERSEN, O.D.
CA410004661OtherRAILROAD MEDICARE
CAZZZ696612OtherBLUE SHIELD
CASD0046000Medicaid
CASD0045740Medicaid
CA1124224589OtherGROUP NPI
CASD0121830Medicaid
CA1043294929OtherRONALD Y. HAYASHIDA, O.D.
CASD0121830Medicaid
CAT09703Medicare UPIN
CAU92857Medicare UPIN
CA1043294929OtherRONALD Y. HAYASHIDA, O.D.
CA410004661OtherRAILROAD MEDICARE
CASD0046000Medicaid
CA1124224589OtherGROUP NPI
CASD0045740Medicaid
CA1215911565OtherCHARLES J. BAUS, O.D.
CA1134103484OtherDENNIS G. LOWMAN O.D.