Basic Information
| Provider Information | |||||||||
| NPI: | 1437375318 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOULWARE | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805388702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706244443 | ||||||||
| FaxNumber: | 9704904175 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 E BOULDER ST | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809095533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196357172 | ||||||||
| FaxNumber: | 7194443717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 02/10/2015 | ||||||||
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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 | 207R00000X | 2006-01834 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0011X | DR.0054836 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | DR.0054836 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.