Basic Information
| Provider Information | |||||||||
| NPI: | 1154785863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARASAWA | ||||||||
| FirstName: | MARIANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6148 DALLAS ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802384389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7204097171 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 55 MADISON ST STE 355 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802065429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033772020 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2016 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0107X | DR.0065005 | CO | Y | 193200000X MULTI-SPECIALTY GROUP |
ID Information
| ID | Type | State | Issuer | Description | 029387 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER | 9000164548 | 05 | CO | MEDICAID |