Healthcare Provider Details

I. General information

NPI: 1245781723
Provider Name (Legal Business Name): OPTUMCARE COLORADO MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6025 DELMONICO DR
COLORADO SPRINGS CO
80919-2251
US

IV. Provider business mailing address

6025 DELMONICO DRIVE
COLORADO SPRINGS CO
80919-2251
US

V. Phone/Fax

Practice location:
  • Phone: 719-535-0648
  • Fax: 719-262-5574
Mailing address:
  • Phone: 719-538-2900
  • Fax: 719-538-2987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateCO

VIII. Authorized Official

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