Provider Demographics
NPI:1811031859
Name:JERRY R. PEDERSON, O.D.
Entity Type:Organization
Organization Name:JERRY R. PEDERSON, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-798-5533
Mailing Address - Street 1:6650 S VINE ST
Mailing Address - Street 2:SUITE 160
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80121-2735
Mailing Address - Country:US
Mailing Address - Phone:303-798-5533
Mailing Address - Fax:303-798-2800
Practice Address - Street 1:6650 S VINE ST
Practice Address - Street 2:SUITE 160
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80121-2735
Practice Address - Country:US
Practice Address - Phone:303-798-5533
Practice Address - Fax:303-798-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO724152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC78053Medicare PIN
COT60730Medicare UPIN