Healthcare Provider Details

I. General information

NPI: 1962709246
Provider Name (Legal Business Name): JOSE EDMUNDO MANRIQUE MERCADO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: EDMUNDO MANRIQUE MD

II. Dates (important events)

Enumeration Date: 02/22/2011
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 ARAPAHOE AVE
BOULDER CO
80303-1131
US

IV. Provider business mailing address

PO BOX 9049
BOULDER CO
80301-9049
US

V. Phone/Fax

Practice location:
  • Phone: 303-415-7610
  • Fax: 303-415-7618
Mailing address:
  • Phone: 303-415-8940
  • Fax: 303-425-9259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0050935
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier90120078
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: