Basic Information
Provider Information | |||||||||
NPI: | 1730849811 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ENDOVASCULAR CONSULTANTS OF COLORADO PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8080 PARK MEADOWS DR STE 150 | ||||||||
Address2: |   | ||||||||
City: | LONE TREE | ||||||||
State: | CO | ||||||||
PostalCode: | 801242566 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7206688818 | ||||||||
FaxNumber: | 7207109492 | ||||||||
Practice Location | |||||||||
Address1: | 291 15TH ST | ||||||||
Address2: |   | ||||||||
City: | BURLINGTON | ||||||||
State: | CO | ||||||||
PostalCode: | 808071619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7206688818 | ||||||||
FaxNumber: | 7207109492 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/30/2021 | ||||||||
LastUpdateDate: | 12/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOVALESKI | ||||||||
AuthorizedOfficialFirstName: | AARON | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5014258489 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 12/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
ID | Type | State | Issuer | Description | DR.0059870 | 01 | CO | COLORADO MEDICAL LICENSE | OTHER |