Healthcare Provider Details

I. General information

NPI: 1447236534
Provider Name (Legal Business Name): EDWARD C MAYNARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 N TEJON ST STE 200
COLORADO SPRINGS CO
80903-1142
US

IV. Provider business mailing address

402 N TEJON ST STE 200
COLORADO SPRINGS CO
80903-1142
US

V. Phone/Fax

Practice location:
  • Phone: 719-633-3850
  • Fax: 719-227-0840
Mailing address:
  • Phone: 719-633-3850
  • Fax: 719-227-0840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30607
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: