Healthcare Provider Details

I. General information

NPI: 1174585400
Provider Name (Legal Business Name): ROBERT RAY MAISEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3676 PARKER BLVD
PUEBLO CO
81008-2212
US

IV. Provider business mailing address

PO BOX 9000
PUEBLO CO
81008-9000
US

V. Phone/Fax

Practice location:
  • Phone: 719-553-2200
  • Fax: 719-553-2216
Mailing address:
  • Phone: 719-553-2200
  • Fax: 719-553-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21020
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: