Healthcare Provider Details

I. General information

NPI: 1578602496
Provider Name (Legal Business Name): MARK R LAUDERMILK PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 S DOWNING ST
DENVER CO
80210-5817
US

IV. Provider business mailing address

10800 E GEDDES AVE STE 300
ENGLEWOOD CO
80112-3895
US

V. Phone/Fax

Practice location:
  • Phone: 303-761-9190
  • Fax: 720-874-4462
Mailing address:
  • Phone: 303-761-9190
  • Fax: 720-874-4462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2356
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: