MEDICARE: EVENSTAR INTERNAL MEDICINE PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	34645	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396967097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVENSTAR INTERNAL MEDICINE PC

Provider Business Mailing Address
First Line	:	6165 LEHMAN DR STE 105
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-5405
Country	:	US
Telephone Number	:	719-528-6929
Fax Number	:	719-528-6900

Provider Business Practice Location Address
First Line	:	6165 LEHMAN DR STE 105
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-5405
Country	:	US
Telephone Number	:	719-528-6929
Fax Number	:	719-528-6900

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. TRUDY G WONG
Credential	:	MD
Telephone Number	:	719-528-6929

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	08/22/2020

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Directions to “EVENSTAR INTERNAL MEDICINE PC ” Practice Location

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