Healthcare Provider Details

I. General information

NPI: 1710744370
Provider Name (Legal Business Name): OPTUMCARE COLORADO MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1536 COLE BLVD STE 4-250
LAKEWOOD CO
80401-3413
US

IV. Provider business mailing address

2 S CASCADE AVE STE 140
COLORADO SPRINGS CO
80903-1604
US

V. Phone/Fax

Practice location:
  • Phone: 303-716-8027
  • Fax: 303-238-5258
Mailing address:
  • Phone: 719-538-2900
  • Fax: 719-538-2990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: EMILY CASTILLO
Title or Position: REGIONAL MEDICAL STAFF MANAGER
Credential:
Phone: 702-579-3253