Basic Information
| Provider Information | |||||||||
| NPI: | 1518215029 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENA | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 6695 W COLFAX AVE | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802141805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202792266 | ||||||||
| FaxNumber: | 3039579787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2012 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2677 | AR | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPT.0003255 | CO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 29168511 | 05 | CO | MEDICAID | OPT.0003255 | 01 | CO | CO OPTOMETRY LICENSE | OTHER |