NPIMap

Organization Active NPI

Southglenn Eyecare, PC

  • Optometrist
  • Centennial, CO
National Provider Identifier
1114167947
Registry record updated Mar 6, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
2468 Issued in CO
Legal business name
SOUTHGLENN EYECARE, PC
Practice address
6650 S Vine St
160
Centennial, CO 80121-2735
Phone
(303) 798-5533
Fax
(303) 798-2800
NPI assigned
Mar 6, 2009
Last updated
Mar 6, 2009By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 6, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jon Frederick Pederson, O.D.NPI 1407842628
Title
Doctor
Phone
(303) 798-5533

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193400000X SINGLE SPECIALTY GROUP 152W00000X 2468 CO Primary

Addresses

Primary practice location

6650 S Vine St
160
Centennial, CO 80121-2735

Mailing address

6650 S Vine St
160
Centennial, CO 80121-2735
Phone (303) 798-5533

Other names 1

  • Jerry R Pederson, O.D., P.C. Other name

National Provider Directory

National Provider Directory
Tax ID family
Jerry R Pederson OD2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1236297600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1236297600000",
    "number": "1114167947",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6650 S VINE ST",
            "address_2": "160",
            "city": "CENTENNIAL",
            "state": "CO",
            "postal_code": "801212735",
            "telephone_number": "303-798-5533",
            "fax_number": "303-798-2800"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6650 S VINE ST",
            "address_2": "160",
            "city": "CENTENNIAL",
            "state": "CO",
            "postal_code": "801212735",
            "telephone_number": "303-798-5533",
            "fax_number": "303-798-2800"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHGLENN EYECARE, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-03-06",
        "last_updated": "2009-03-06",
        "status": "A",
        "authorized_official_last_name": "PEDERSON",
        "authorized_official_first_name": "JON",
        "authorized_official_middle_name": "FREDERICK",
        "authorized_official_title_or_position": "DOCTOR",
        "authorized_official_telephone_number": "303-798-5533",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": "CO",
            "license": "2468",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jerry R Pederson, O.D., P.C.",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Centennial, CO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 6, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.