Provider Demographics
NPI:1780762781
Name:CUCKLER, JONATHON JAMES (OPTICIAN)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:JAMES
Last Name:CUCKLER
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 BOLTZ CT
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2801
Mailing Address - Country:US
Mailing Address - Phone:970-377-0592
Mailing Address - Fax:
Practice Address - Street 1:1931 65TH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-7945
Practice Address - Country:US
Practice Address - Phone:970-356-1047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO143242156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0735500001Medicare NSC