Healthcare Provider Details

I. General information

NPI: 1699895755
Provider Name (Legal Business Name): ROCKY MOUNTAIN PEDIATRIC GASTROENTEROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10465 PARK MEADOWS DR STE 201
LONE TREE CO
80124-5321
US

IV. Provider business mailing address

10465 PARK MEADOWS DR STE 201
LONE TREE CO
80124-5321
US

V. Phone/Fax

Practice location:
  • Phone: 303-790-1515
  • Fax: 303-790-1989
Mailing address:
  • Phone: 303-790-1515
  • Fax: 303-790-1989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. THEODORE H. STATHOS
Title or Position: AUTHORIZED OFFICIAL, PRESIDENT
Credential: MD
Phone: 303-790-1515