MEDICARE: SOURAV PODDAR MD

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	207QS0010X	Sports Medicine (Family Medicine) Physician	37379	CO
2	207Q00000X	Family Medicine Physician	37379	CO

General Provider Information

NPI Number	:	1750496733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOURAV PODDAR MD

Provider Business Mailing Address
First Line	:	PO BOX 110429
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80042-0429
Country	:	US
Telephone Number	:	303-493-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 S COLORADO BLVD
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80222-7900
Country	:	US
Telephone Number	:	720-848-8201
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	11/04/2022

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