Provider Demographics
NPI:1629795851
Name:BOULDER EYE SURGEONS
Entity Type:Organization
Organization Name:BOULDER EYE SURGEONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:NIKISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-773-7144
Mailing Address - Street 1:PO BOX 200564
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-0564
Mailing Address - Country:US
Mailing Address - Phone:307-773-7144
Mailing Address - Fax:
Practice Address - Street 1:1810 30TH ST STE B
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1025
Practice Address - Country:US
Practice Address - Phone:720-358-9415
Practice Address - Fax:303-499-2020
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOULDER EYE SURGEONS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty