Healthcare Provider Details

I. General information

NPI: 1104081637
Provider Name (Legal Business Name): CHAMISA MACINDOE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 E BOULDER ST STE 101
COLORADO SPRINGS CO
80909
US

IV. Provider business mailing address

1725 E BOULDER ST STE 101
COLORADO SPRINGS CO
80909-5740
US

V. Phone/Fax

Practice location:
  • Phone: 719-365-6300
  • Fax: 719-365-6094
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA-1568-10
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS014360
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDR.0051667
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License NumberDR.0051667
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: