Healthcare Provider Details

I. General information

NPI: 1154890291
Provider Name (Legal Business Name): BRIAN P GRADISEK DPM PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 28TH ST STE 2
BOULDER CO
80303-1096
US

IV. Provider business mailing address

PO BOX 21150
BOULDER CO
80308-4150
US

V. Phone/Fax

Practice location:
  • Phone: 303-449-2000
  • Fax: 303-449-9475
Mailing address:
  • Phone: 303-546-9158
  • Fax: 303-546-9107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
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: BRIAN P GRADISEK
Title or Position: OWNER
Credential: DPM
Phone: 303-449-2000