MEDICARE: OPTUMCARE COLORADO MEDICAL GROUP LLC

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	133V00000X	Registered Dietitian		CO
2	207RS0012X	Sleep Medicine (Internal Medicine) Physician

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	:	1770714339
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTUMCARE COLORADO MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	PO BOX 35380
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89133-5380
Country	:	US
Telephone Number	:	702-579-3203
Fax Number	:	719-538-2990

Provider Business Practice Location Address
First Line	:	1625 MEDICAL CENTER PT STE 210
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-5798
Country	:	US
Telephone Number	:	719-635-5803
Fax Number	:	719-448-0164

Authorized Official
Title or Position	:	ASSOCIATE DIRECTOR CREDENTIALING
Name	:	EMILY CASTILLO
Credential	:
Telephone Number	:	702-579-3253

Provider Enumeration Date	:	07/30/2009
Last Update Date	:	08/20/2024

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