Provider Demographics
NPI:1336123686
Name:PEDERSEN, BARTON MILO (OD)
Entity Type:Individual
Prefix:MR
First Name:BARTON
Middle Name:MILO
Last Name:PEDERSEN
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 1:56970 YUCCA TRL
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
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
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT4600T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0046000Medicaid
CA1124224589OtherGROUP NPI
CA410004661OtherRAILROAD MEDICARE
CA0313520001OtherDMERC M/C REGION D
CAGSD004460OtherMEDICAID GROUP NUMBER
CAZZZ24908ZOtherMEDICARE CLINIC GROUP NUM
CA410004661OtherRAILROAD MEDICARE
CASD0046000Medicare ID - Type Unspecified
CASD0046000Medicaid
CA1124224589Medicare NSC