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NPI Code Detail

MEDICARE: DR. ERIC PHILIP MEDIAVILLA DDS

MEDICARE: DR. ERIC PHILIP MEDIAVILLA DDS
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
11223G0001XGeneral Practice Dentistry8322CO

Other Identifiers

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

General Provider Information

NPI Number : 1518004274
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ERIC PHILIP MEDIAVILLA DDS
Provider Business Mailing Address
First Line : 10036 PALISADE RIDGE DR
Second Line :
City : COLORADO SPRINGS
State : CO
Zip : 80920-1491
Country : US
Telephone Number : 303-588-5349
Fax Number :
Provider Business Practice Location Address
First Line : 513 KIVA RD
Second Line :
City : COLORADO SPRINGS
State : CO
Zip : 80911-1913
Country : US
Telephone Number : 303-588-5349
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/31/2007
Last Update Date : 07/08/2007

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