Healthcare Provider Details

I. General information

NPI: 1134478365
Provider Name (Legal Business Name): JOSE IGNACIO MAYORDOMO M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BANNOCK ST
DENVER CO
80204-4507
US

IV. Provider business mailing address

AVE. JUAN PABLO II, 66 11B
ZARAGOZA ZARAGOZA
50009
ES

V. Phone/Fax

Practice location:
  • Phone: 303-436-6900
  • Fax:
Mailing address:
  • Phone: 01134645312941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberTDP.0041921
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: