MEDICARE: COLORADO RETINA ASSOCIATES, PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207WX0107X	Retina Specialist (Ophthalmology) Physician
2	207WX0108X	Uveitis and Ocular Inflammatory Disease (Ophthalmology) Physician
3	261QM2500X	Medical Specialty Clinic/Center

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497389399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLORADO RETINA ASSOCIATES, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 17949
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80217-0949
Country	:	US
Telephone Number	:	303-261-1600
Fax Number	:	303-261-1601

Provider Business Practice Location Address
First Line	:	850 ENGLEWOOD PKWY STE 200
Second Line	:
City	:	ENGLEWOOD
State	:	CO
Zip	:	80110-7399
Country	:	US
Telephone Number	:	303-261-1600
Fax Number	:	303-261-1601

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	KYLIE WAKASUGI
Credential	:
Telephone Number	:	303-261-1600

Provider Enumeration Date	:	02/28/2020
Last Update Date	:	06/14/2022

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