1922351279 NPI number — INFECTIOUS DISEASE SPECIALIST OF SOUTHERN COLORADO, PLLC

Table of content: (NPI 1922351279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922351279 NPI number — INFECTIOUS DISEASE SPECIALIST OF SOUTHERN COLORADO, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INFECTIOUS DISEASE SPECIALIST OF SOUTHERN COLORADO, 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:
Provider Other Organization Name Type Code:
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:
1922351279
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 470238
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80047-0238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-582-8425
Provider Business Mailing Address Fax Number:
888-719-1380

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 LAKE AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81004-3538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-582-8425
Provider Business Practice Location Address Fax Number:
888-719-1380
Provider Enumeration Date:
10/24/2012

Additional Information

Authorized Official

Authorized Official Last Name:
NWANGUMA
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
719-582-8425

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  DR51262 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1336601387 . This is a "NPI" identifier . This identifiers is of the category "OTHER".




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