Provider Demographics
NPI:1558544833
Name:FORT LUPTON VISION CENTER PC
Entity Type:Organization
Organization Name:FORT LUPTON VISION CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIMONSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-857-6550
Mailing Address - Street 1:301 DENVER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1821
Mailing Address - Country:US
Mailing Address - Phone:303-857-6550
Mailing Address - Fax:303-857-6596
Practice Address - Street 1:301 DENVER AVE
Practice Address - Street 2:
Practice Address - City:FORT LUPTON
Practice Address - State:CO
Practice Address - Zip Code:80621-1821
Practice Address - Country:US
Practice Address - Phone:303-857-6550
Practice Address - Fax:303-857-6596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2357152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODP2823OtherRAILROAD MEDICARE GROUP PTAN
CO5808690001Medicare NSC
CODP2823OtherRAILROAD MEDICARE GROUP PTAN
COV01360Medicare UPIN