Provider Demographics
NPI:1730165275
Name:HENDRICKS, JERRY ALLEN (OD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:ALLEN
Last Name:HENDRICKS
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 1:6005 DELMONICO DR
Mailing Address - Street 2:SUITE 140, ROCKRIMMON VISION CLINIC
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2237
Mailing Address - Country:US
Mailing Address - Phone:719-522-9393
Mailing Address - Fax:719-532-1114
Practice Address - Street 1:6005 DELMONICO DR
Practice Address - Street 2:SUITE 140, ROCKRIMMON VISION CLINIC
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-2237
Practice Address - Country:US
Practice Address - Phone:719-522-9393
Practice Address - Fax:719-532-1114
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO1973152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
E8023Medicare ID - Type Unspecified
U71545Medicare UPIN
COCE8003Medicare PIN