=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891082491
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN NIKOLAY BANGIYEV D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2011
-----------------------------------------------------
Last Update Date | 02/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2055 N HIGH ST STE 110
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80205-5504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-301-9019
-----------------------------------------------------
Fax | 303-861-6254
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2055 N HIGH ST STE 110
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80205-5504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-301-9019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YS0123X
-----------------------------------------------------
Taxonomy Name | Facial Plastic Surgery Physician
-----------------------------------------------------
License Number | 5101019122
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207YP0228X
-----------------------------------------------------
Taxonomy Name | Pediatric Otolaryngology Physician
-----------------------------------------------------
License Number | 58725
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------