Provider Demographics
NPI:1326047077
Name:LERVICK, DALE G (OD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:G
Last Name:LERVICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7586 W JEWELL AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80232-6890
Mailing Address - Country:US
Mailing Address - Phone:303-233-7575
Mailing Address - Fax:303-233-4740
Practice Address - Street 1:7586 W JEWELL AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80232-6890
Practice Address - Country:US
Practice Address - Phone:303-233-7575
Practice Address - Fax:303-233-4740
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO777152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08007775Medicaid
CO32959OtherBLUE CROSS
CO08007775Medicaid
CO32959OtherBLUE CROSS
COC77013Medicare PIN