Provider Demographics
NPI:1164493631
Name:PEDERSEN, RICHARD T (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:T
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 E PLATTE AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5620
Mailing Address - Country:US
Mailing Address - Phone:719-634-4327
Mailing Address - Fax:719-633-0284
Practice Address - Street 1:1625 E PLATTE AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5620
Practice Address - Country:US
Practice Address - Phone:719-634-4327
Practice Address - Fax:719-633-0284
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO860152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0275490001Medicare NSC
COC78073Medicare PIN