Healthcare Provider Details

I. General information

NPI: 1588817464
Provider Name (Legal Business Name): BOULDER ENDOCRINOLOGY PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2008
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

892 W SOUTH BOULDER RD
LOUISVILLE CO
80027-2453
US

IV. Provider business mailing address

892 W SOUTH BOULDER RD
LOUISVILLE CO
80027-2453
US

V. Phone/Fax

Practice location:
  • Phone: 303-586-5200
  • Fax: 303-586-5201
Mailing address:
  • Phone: 303-586-5200
  • Fax: 303-586-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number45001
License Number StateCO

VIII. Authorized Official

Name: KELLY A. MANDAGERE
Title or Position: M.D.
Credential:
Phone: 303-586-5200