Healthcare Provider Details

I. General information

NPI: 1215170600
Provider Name (Legal Business Name): COLORADO CYBERMED, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10463 PARK MEADOWS DR SUITE 114
LONE TREE CO
80124-5316
US

IV. Provider business mailing address

10463 PARK MEADOWS DR SUITE 114
LONE TREE CO
80124-5316
US

V. Phone/Fax

Practice location:
  • Phone: 303-532-2130
  • Fax: 303-532-2131
Mailing address:
  • Phone: 303-532-2130
  • Fax: 303-532-2131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberPENDING
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License NumberPENDING
License Number StateCO

VIII. Authorized Official

Name: GREGG A DICKERSON
Title or Position: OWNER
Credential: MD
Phone: 303-532-2130