Healthcare Provider Details

I. General information

NPI: 1730175688
Provider Name (Legal Business Name): CHARLES ERNEST FUENZALIDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 01/26/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1444 S POTOMAC ST SUITE 300
AURORA CO
80012-4508
US

IV. Provider business mailing address

4900 S MONACO ST SUITE 210
DENVER CO
80237-3486
US

V. Phone/Fax

Practice location:
  • Phone: 303-750-0822
  • Fax: 303-750-1298
Mailing address:
  • Phone: 303-750-0822
  • Fax: 303-750-1298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number25164
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25164
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: