Basic Information
| Provider Information | |||||||||
| NPI: | 1558463307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEMIDOVICH | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 E HARVARD AVE | ||||||||
| Address2: | STE 440 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802107009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037442704 | ||||||||
| FaxNumber: | 3037443244 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 E HARVARD AVE | ||||||||
| Address2: | STE 440 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802107009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037442704 | ||||||||
| FaxNumber: | 3037443244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 05/17/2013 | ||||||||
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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 | 207N00000X | 33910 | CO | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 19292 | 01 | CO | BCBS | OTHER | 01339100 | 05 | CO | MEDICAID | 84-1511239 | 01 | CO | FEDERAL TAX ID | OTHER | 070015071 | 01 | CO | RR MEDICARE | OTHER |