Provider Demographics
NPI:1700166121
Name:BERT, JILL MARGARET (OD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:MARGARET
Last Name:BERT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5773 W 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80214-1695
Mailing Address - Country:US
Mailing Address - Phone:708-519-0123
Mailing Address - Fax:303-427-8772
Practice Address - Street 1:1931 SHERIDAN BLVD
Practice Address - Street 2:SUITE S
Practice Address - City:EDGEWATER
Practice Address - State:CO
Practice Address - Zip Code:80214-1316
Practice Address - Country:US
Practice Address - Phone:303-578-8055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003048152WV0400X, 152WX0102X, 152WC0802X, 152WL0500X, 152WP0200X, 152W00000X
COOPT0003048152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO63605376Medicaid
CO63605376Medicaid
IL046010461Medicaid
CO3936462Medicare PIN