Basic Information
| Provider Information | |||||||||
| NPI: | 1245411958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CZUCZMAN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10700 E GEDDES AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Practice Location | |||||||||
| Address1: | 10700 E GEDDES AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801123861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037619190 | ||||||||
| FaxNumber: | 7208744462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 29962 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 239318 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 52616 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 561677YQN9 | 01 | CO | MEDICARE PIN | OTHER | 1245411958 | 05 | CO | MEDICAID | KA3249099 | 01 | KS | MEDICARE PIN | OTHER | 111257108 | 01 | KS | MEDICARE PIN | OTHER | NA1215116 | 01 | NE | MEDICARE PIN | OTHER | 561677YQ33 | 01 | CO | MEDICARE PIN | OTHER | 561677YQPG | 01 | CO | MEDICARE PIN | OTHER | 561677ZNTB | 01 | CO | MEDICARE PIN | OTHER | 561677ZLJ3 | 01 | CO | MEDICARE PIN | OTHER | NA1214115 | 01 | NE | MEDICARE PIN | OTHER | NA2517094 | 01 | NE | MEDICARE PIN | OTHER |