Healthcare Provider Details

I. General information

NPI: 1265674287
Provider Name (Legal Business Name): MARCHYARN MAHATHANARUK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11700 W 2ND PL STE 225
LAKEWOOD CO
80228-1707
US

IV. Provider business mailing address

PO BOX 800022
KANSAS CITY MO
64180-0022
US

V. Phone/Fax

Practice location:
  • Phone: 303-661-4100
  • Fax: 720-321-8969
Mailing address:
  • Phone: 800-953-0104
  • Fax: 303-765-6670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberDR.0054219
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: