Healthcare Provider Details

I. General information

NPI: 1942041603
Provider Name (Legal Business Name): OPTUMCARE COLORADO MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 RESEARCH PKWY
COLORADO SPRINGS CO
80920-1044
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 719-574-9191
  • Fax:
Mailing address:
  • Phone: 719-400-7470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: EMILY CASTILLO
Title or Position: ASSOCIATE DIRECTOR CREDENTIALING
Credential:
Phone: 702-579-3253