Healthcare Provider Details

I. General information

NPI: 1689631822
Provider Name (Legal Business Name): JERRY S MIKLIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3655 LUTHERAN PKWY SUITE 201
WHEAT RIDGE CO
80033-6018
US

IV. Provider business mailing address

500 ELDORADO BLVD SUITE 6250
BROOMFIELD CO
80021-3408
US

V. Phone/Fax

Practice location:
  • Phone: 303-603-9800
  • Fax: 303-403-6209
Mailing address:
  • Phone: 303-272-0750
  • Fax: 303-318-2488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25248
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number25248
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number25248
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: