Healthcare Provider Details

I. General information

NPI: 1770726101
Provider Name (Legal Business Name): ROGER PAUL ILVONEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2009
Last Update Date: 04/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2337 S YOUNGFIELD WAY
LAKEWOOD CO
80228-4970
US

IV. Provider business mailing address

2337 S YOUNGFIELD WAY
LAKEWOOD CO
80228-4970
US

V. Phone/Fax

Practice location:
  • Phone: 303-986-2827
  • Fax: 303-986-5720
Mailing address:
  • Phone: 303-986-2827
  • Fax: 303-986-5720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number18649
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: