Basic Information
| Provider Information | |||||||||
| NPI: | 1104157775 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORTERCARE ADVENTIST HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COLORADO ENT SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911244 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802911244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036431099 | ||||||||
| FaxNumber: | 3036431176 | ||||||||
| Practice Location | |||||||||
| Address1: | 9399 CROWN CREST BLVD | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | PARKER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801388506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202742544 | ||||||||
| FaxNumber: | 7202742541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2010 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WATSON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | C.M.O. | ||||||||
| AuthorizedOfficialTelephone: | 3036737181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 80353568 | 05 | CO | MEDICAID | 20422571 | 05 | CO | MEDICAID |