Healthcare Provider Details

I. General information

NPI: 1447753678
Provider Name (Legal Business Name): GARRETT WAYNE ROTA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 E PIKES PEAK AVE
COLORADO SPRINGS CO
80909-6004
US

IV. Provider business mailing address

1000 S BROADWAY APT 237
DENVER CO
80209-4095
US

V. Phone/Fax

Practice location:
  • Phone: 719-634-2001
  • Fax: 719-634-2211
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberDR.0067795
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: