Healthcare Provider Details

I. General information

NPI: 1013548395
Provider Name (Legal Business Name): OPTUMCARE COLORADO MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17230 JACKSON CREEK PKWY STE 260
MONUMENT CO
80132-7305
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 719-488-6998
  • Fax: 719-488-8270
Mailing address:
  • Phone: 719-538-2990
  • Fax: 719-538-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID I COHEN
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 702-480-2550