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SOUTHGLENN EYECARE, PC
NPI 1073742938
Optometrist in Centennial, CO

Active since July 13, 2009
6650 S VINE ST, SUITE 160, CENTENNIAL, CO 80121(303) 798-5533(303) 798-2800 Get Directions Write a Review

NPPES record last updated: September 15, 2020. Verified against the NPPES registry weekly; last sync: October 25, 2026.

Record update history: Sep 15, 2020, Sep 1, 2020 (2 updates tracked since 2020).

About Southglenn Eyecare, Pc NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

SOUTHGLENN EYECARE, PC (NPI 1073742938) is a healthcare organization registered as an optometrist in Centennial, Colorado and active in the NPI registry since July 2009. The organization lists Jon F Pederson, Owner, as its authorized official.

NPPES Registry Identity

NPI1073742938
Entity TypeOrganization
Primary Taxonomy152W00000X
Legal Business NameJERRY R. PEDERSON, O.D., P.C.
Location Address6650 S VINE ST, SUITE 160Centennial, CO 80121-2769
Mailing Address6650 S Vine St, Suite 160Centennial, CO 80121-2769 · (303) 798-5533 · Fax (303) 798-2800
Phone(303) 798-5533
Fax(303) 798-2800
Organization SubpartNo
Authorized OfficialJon F PedersonOwner · (303) 798-5533
Enumeration DateJuly 13, 2009
Last NPPES UpdateSeptember 15, 20202 updates tracked since enumeration
NPPES CertifiedSeptember 15, 2020
✔ NPI 1073742938 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyOptometristEye and Vision Services Providers
Taxonomy Code152W00000X
Definition
Doctors of optometry (ODs) are the primary health care professionals for the eye. Optometrists examine, diagnose, treat, and manage diseases, injuries, and disorders of the visual system, the eye, and associated structures as well as identify related systemic conditions affecting the eye. An optometrist has completed pre-professional undergraduate education in a college or university and four years of professional education at a college of optometry, leading to the doctor of optometry (O.D.) degree. Some optometrists complete an optional residency in a specific area of practice. Optometrists are eye health care professionals state-licensed to diagnose and treat diseases and disorders of the eye and visual system.
6650 S VINE ST, Centennial, CO 80121
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Other Names 1

Doing Business AsSouthglenn Eyecare, Pc

Group Practice 1

Group TaxonomyThis provdier is a business group of one or more individual practitioners, all of who practice with the same area of specialization.193400000X SINGLE SPECIALTY GROUP

Medicare Participation & PECOS CMS

Medicare enrollment, revalidation and the clinicians who bill Medicare through this organization, from CMS.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Southglenn Eyecare, Pc is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

Medicare Revalidation Due Date

Revalidation due by November 30, 2026

Medicare-enrolled providers and suppliers confirm their enrollment information with CMS on a set cycle, every 5 years for most and every 3 years for medical equipment suppliers. CMS sets the due date for each enrollment.

StateEnrollment IDDue date
StateColoradoEnrollment IDO20090810000171Non-DME Part B · Clinic/Group PracticeDue dateNovember 30, 2026
Source: CMS Revalidation Due Date List, October 2026 release.

Clinicians Billing Medicare Through This Organization

2

Medicare enrollment records show 2 clinicians reassign Medicare billing to Southglenn Eyecare, PC, which bills Medicare for the services they deliver. Of these, 1 practice at this address. They are listed nearest first.

Clinicians, nearest first (2)

Jon Pederson, OD
Optometry
NPI 1407842628
6650 S VINE ST STE 160
Centennial, CO 80121
(303) 798-5533
✔ PECOS✔ Accepts MedicareSame address
Samantha Kincaid, O.D.
Optometry
NPI 1629483144
9235 CROWN CREST BLVD STE 150
Parker, CO 80138
(303) 840-6268
✔ PECOS✔ Accepts Medicare11 mi

Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Jerry R. Pederson, O.D., P.C.'s NPI number?

The NPI number for Jerry R. Pederson, O.D., P.C. is 1073742938. It was assigned to this organization in the NPPES registry on July 13, 2009. The provider is doing business as Southglenn Eyecare, PC.

Where is Jerry R. Pederson, O.D., P.C. located?

Jerry R. Pederson, O.D., P.C. is located at 6650 S Vine St Suite 160, Centennial, CO 80121. The listed phone number is (303) 798-5533.

What is Jerry R. Pederson, O.D., P.C.'s specialty?

The primary specialty registered for this NPI is Optometrist with taxonomy code 152W00000X.

Is Jerry R. Pederson, O.D., P.C. enrolled in Medicare?

Yes. Jerry R. Pederson, O.D., P.C. is registered in the Medicare PECOS enrollment system.

When is Jerry R. Pederson, O.D., P.C.'s Medicare revalidation due?

According to the CMS Revalidation Due Date List (October 2026 release), the Medicare Non-DME Part B enrollment for this organization (Colorado, Clinic/Group Practice) is due for revalidation by November 30, 2026. Medicare providers and suppliers revalidate their enrollment every 5 years, and medical equipment suppliers every 3 years. Confirm current requirements with your Medicare Administrative Contractor.

How many clinicians bill Medicare through Jerry R. Pederson, O.D., P.C.?

According to the CMS Revalidation Reassignment List (October 2026 release), 2 clinicians, all in Optometry, reassign their Medicare billing to Jerry R. Pederson, O.D., P.C.. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. Of these, 1 practice at this address. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

When was this NPI record last updated?

The NPPES record for Jerry R. Pederson, O.D., P.C. was last updated on September 15, 2020. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 6 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.