1154955896 NPI number — COLORADO RETINA ASSOCIATES, PLLC

Table of content: (NPI 1154955896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154955896 NPI number — COLORADO RETINA ASSOCIATES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLORADO RETINA ASSOCIATES, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COLORADO RETINA ASSOCIATES, PC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154955896
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
06/14/2022
NPI Reactivation Date:
12/02/2022

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 17949
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80217-0949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-261-1600
Provider Business Mailing Address Fax Number:
303-261-1601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 INDIANA ST STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOLDEN
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80401-5033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-261-1600
Provider Business Practice Location Address Fax Number:
303-261-1601
Provider Enumeration Date:
03/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
WAKASUGI
Authorized Official First Name:
KYLIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
303-261-1600

Provider Taxonomy Codes

  • Taxonomy code: 207WX0107X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207WX0108X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05958008 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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