Healthcare Provider Details

I. General information

NPI: 1104001379
Provider Name (Legal Business Name): UROLOGY OF SOUTHERN COLORADO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 10/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3676 PARKER BLVD SUITE 310
PUEBLO CO
81008-2212
US

IV. Provider business mailing address

3676 PARKER BLVD SUITE 310
PUEBLO CO
81008-2212
US

V. Phone/Fax

Practice location:
  • Phone: 719-545-1500
  • Fax:
Mailing address:
  • Phone: 719-545-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number40134
License Number StateCO

VIII. Authorized Official

Name: DANA JOAN WEAVER-OSTERHOLTZ
Title or Position: OWNER
Credential: M.D.
Phone: 719-676-3728