Healthcare Provider Details

I. General information

NPI: 1639609480
Provider Name (Legal Business Name): RENEE LYNN DOMOZYCH PRIDE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RENEE LYNN DOMOZYCH MD

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 E CHERRY CREEK SOUTH DR STE 600
DENVER CO
80246-1500
US

IV. Provider business mailing address

4500 E CHERRY CREEK SOUTH DR STE 600
DENVER CO
80246-1500
US

V. Phone/Fax

Practice location:
  • Phone: 303-355-3000
  • Fax:
Mailing address:
  • Phone: 631-258-4565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number64083
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number28956
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number64083
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: