Healthcare Provider Details

I. General information

NPI: 1841532603
Provider Name (Legal Business Name): MARIYA GUSMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BANNOCK ST
DENVER CO
80204-4597
US

IV. Provider business mailing address

777 BANNOCK ST
DENVER CO
80204-4597
US

V. Phone/Fax

Practice location:
  • Phone: 303-643-6494
  • Fax: 303-602-4168
Mailing address:
  • Phone: 303-643-6494
  • Fax: 303-602-4168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberDR.0074869
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberDR.0074869
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: