Healthcare Provider Details

I. General information

NPI: 1760406359
Provider Name (Legal Business Name): JAG MOHAN S WALIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E FONTANERO ST
COLORADO SPRINGS CO
80907-7529
US

IV. Provider business mailing address

320 E FONTANERO ST
COLORADO SPRINGS CO
80907-7529
US

V. Phone/Fax

Practice location:
  • Phone: 719-866-6218
  • Fax:
Mailing address:
  • Phone: 719-866-6218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number40287
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: