Healthcare Provider Details

I. General information

NPI: 1053463836
Provider Name (Legal Business Name): SOUTHERN COLORADO VASCULAR SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 12/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 N CIRCLE DR STE 115
COLORADO SPRINGS CO
80909-1163
US

IV. Provider business mailing address

2960 N CIRCLE DR STE 115
COLORADO SPRINGS CO
80909-1163
US

V. Phone/Fax

Practice location:
  • Phone: 719-630-3465
  • Fax: 719-630-3476
Mailing address:
  • Phone: 719-630-3465
  • Fax: 719-630-3476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number38531
License Number StateCO

VIII. Authorized Official

Name: DR. BRUCE DONALD MISARE
Title or Position: PHYSICIAN
Credential: MD
Phone: 719-630-3465