Healthcare Provider Details

I. General information

NPI: 1265929814
Provider Name (Legal Business Name): CONIFER PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26719 PLEASANT PARK RD UNIT 120
CONIFER CO
80433-7753
US

IV. Provider business mailing address

30960 STAGECOACH BLVD # W-120
EVERGREEN CO
80439-7902
US

V. Phone/Fax

Practice location:
  • Phone: 303-838-7337
  • Fax: 303-816-6387
Mailing address:
  • Phone: 303-674-6671
  • Fax: 303-674-0031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number26133
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KENNETH JOHN KUTALEK
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 303-674-6671