Healthcare Provider Details

I. General information

NPI: 1922893478
Provider Name (Legal Business Name): OPTUMCARE COLORADO MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2503 WALNUT ST STE 200
BOULDER CO
80302-5745
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 720-494-4700
  • Fax: 720-494-4706
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: EMILY CASTILLO
Title or Position: ASSOCIATE DIRECTOR
Credential:
Phone: 702-480-2550