Basic Information
Provider Information | |||||||||
NPI: | 1689631822 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MIKLIN | ||||||||
FirstName: | JERRY | ||||||||
MiddleName: | S | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 ELDORADO BLVD | ||||||||
Address2: | SUITE 6250 | ||||||||
City: | BROOMFIELD | ||||||||
State: | CO | ||||||||
PostalCode: | 800213408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3032720750 | ||||||||
FaxNumber: | 3033182488 | ||||||||
Practice Location | |||||||||
Address1: | 3655 LUTHERAN PKWY | ||||||||
Address2: | SUITE 201 | ||||||||
City: | WHEAT RIDGE | ||||||||
State: | CO | ||||||||
PostalCode: | 800336018 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036039800 | ||||||||
FaxNumber: | 3034036209 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2006 | ||||||||
LastUpdateDate: | 07/29/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 25248 | CO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 25248 | CO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207UN0901X | 25248 | CO | N |   | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology |
ID Information
ID | Type | State | Issuer | Description | 01252485 | 05 | CO |   | MEDICAID |