Healthcare Provider Details

I. General information

NPI: 1003234030
Provider Name (Legal Business Name): STEFAN MICHAEL BUMOL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 E 12TH AVE
DENVER CO
80220-2415
US

IV. Provider business mailing address

4455 E 12TH AVE
DENVER CO
80220-2415
US

V. Phone/Fax

Practice location:
  • Phone: 303-504-7700
  • Fax:
Mailing address:
  • Phone: 303-504-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDR.0062808
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: