Healthcare Provider Details

I. General information

NPI: 1124463161
Provider Name (Legal Business Name): SOUTH DENVER PHYSICIANS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13111 E BRIARWOOD AVE #370
CENTENNIAL CO
80112
US

IV. Provider business mailing address

13111 E BRIARWOOD AVE SUITE #370
CENTENNIAL CO
80112-3930
US

V. Phone/Fax

Practice location:
  • Phone: 720-441-4410
  • Fax: 888-474-7158
Mailing address:
  • Phone: 720-441-4410
  • Fax: 888-474-7158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number46797
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number47080
License Number StateCO

VIII. Authorized Official

Name: DMITRIY I PALES
Title or Position: SOLE MEMBER
Credential: DO
Phone: 720-441-4410