Basic Information
Provider Information | |||||||||
NPI: | 1699760173 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FRIEDMAN | ||||||||
FirstName: | MARC | ||||||||
MiddleName: | JEFFREY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1725 E. BOULDER ST. | ||||||||
Address2: | STE 101 | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809095740 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7193656300 | ||||||||
FaxNumber: | 7193656094 | ||||||||
Practice Location | |||||||||
Address1: | 1725 E BOULDER ST | ||||||||
Address2: | STE 101 | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809095768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7193656300 | ||||||||
FaxNumber: | 7193656094 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2005 | ||||||||
LastUpdateDate: | 02/20/2012 | ||||||||
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 | 2084N0400X | DR-27389 | CO | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 32026838 | 05 | CO |   | MEDICAID |