Healthcare Provider Details

I. General information

NPI: 1023234861
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF SOUTHERN COLORADO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 N GRAND AVE
PUEBLO CO
81003-2718
US

IV. Provider business mailing address

2020 WADSWORTH BLVD SUITE 13A
LAKEWOOD CO
80214-5728
US

V. Phone/Fax

Practice location:
  • Phone: 719-544-2090
  • Fax: 719-544-2094
Mailing address:
  • Phone: 303-238-0471
  • Fax: 303-238-6711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: PUDUPAKKAM K VEDANTHAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 303-238-0471