=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518479799
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DONNA VISHNEVETSKY MD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2017
-----------------------------------------------------
Last Update Date | 10/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3801 E FLORIDA AVE
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80210-2571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-504-7859
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3801 E FLORIDA AVE
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80210-2571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-504-7859
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DONNA VISHNEVETSKY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 720-504-7859
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 50460
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------