Basic Information
| Provider Information | |||||||||
| NPI: | 1114910759 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORNEAL CONSULTANTS OF COLORADO PC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COLORADO EYE CONSULTANTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 W MINERAL AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801205612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037300404 | ||||||||
| FaxNumber: | 3037306163 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 W MINERAL AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801205612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037300404 | ||||||||
| FaxNumber: | 7206474210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FORSTOT | ||||||||
| AuthorizedOfficialFirstName: | STEPHAN | ||||||||
| AuthorizedOfficialMiddleName: | LANCE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3037300404 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | B4508 | 01 | BLUE CROSS BLUE SHIELD | OTHER | CC7541 | 01 | RAILROAD MEDICARE | OTHER | 04005146 | 05 | CO | MEDICAID |