Healthcare Provider Details

I. General information

NPI: 1942265624
Provider Name (Legal Business Name): CHERRY CREEK PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 E KENTUCKY AVE
DENVER CO
80246-2365
US

IV. Provider business mailing address

4900 E KENTUCKY AVE
DENVER CO
80246-2365
US

V. Phone/Fax

Practice location:
  • Phone: 303-756-0101
  • Fax: 303-756-1408
Mailing address:
  • Phone: 303-756-0101
  • Fax: 303-756-1408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number24963
License Number StateCO

VIII. Authorized Official

Name: JODY L MATHIE
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 303-756-0101