MEDICARE: CASTLE ROCK PEDIATRICS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	31685	CO

General Provider Information

NPI Number	:	1548289614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CASTLE ROCK PEDIATRICS PLLC

Provider Business Mailing Address
First Line	:	410 S WILCOX ST STE 102
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-2663
Country	:	US
Telephone Number	:	303-688-2228
Fax Number	:	303-663-0640

Provider Business Practice Location Address
First Line	:	410 S WILCOX ST STE 102
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-2663
Country	:	US
Telephone Number	:	303-688-2228
Fax Number	:	303-663-0640

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN MARK BOUCHILLON
Credential	:	MD
Telephone Number	:	303-688-2228

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	05/29/2026

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