Provider Demographics
NPI:1275632192
Name:PONDEROSA VISION CLINIC PC
Entity Type:Organization
Organization Name:PONDEROSA VISION CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-693-9561
Mailing Address - Street 1:14991 E HAMPDEN AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-3980
Mailing Address - Country:US
Mailing Address - Phone:303-693-9561
Mailing Address - Fax:303-693-0713
Practice Address - Street 1:14991 E HAMPDEN AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-3980
Practice Address - Country:US
Practice Address - Phone:303-693-9561
Practice Address - Fax:303-693-0713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35337RTSL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCF2903Medicare PIN
CO0191530002Medicare NSC