Healthcare Provider Details

I. General information

NPI: 1932101490
Provider Name (Legal Business Name): MARIO J IMOLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 S LOGAN ST SUITE 100
ENGLEWOOD CO
80113-3766
US

IV. Provider business mailing address

3600 S LOGAN ST SUITE 100
ENGLEWOOD CO
80113-3766
US

V. Phone/Fax

Practice location:
  • Phone: 303-839-7980
  • Fax: 303-839-7936
Mailing address:
  • Phone: 303-839-7980
  • Fax: 303-839-7936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number38335
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: