Healthcare Provider Details

I. General information

NPI: 1699972992
Provider Name (Legal Business Name): ANANYA GUHA LUSERO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 PHAY AVE SUITE A
CANON CITY CO
81212-2334
US

IV. Provider business mailing address

1335 PHAY AVE SUITE A
CANON CITY CO
81212-2334
US

V. Phone/Fax

Practice location:
  • Phone: 719-285-2091
  • Fax: 719-285-2092
Mailing address:
  • Phone: 719-285-2091
  • Fax: 719-285-2092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRS20070322
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR.0054382
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: