Basic Information
| Provider Information | |||||||||
| NPI: | 1225162134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JERRY K POPHAM, MD PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PARK AVENUE OCULOPLASTIC SURGEONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1800 EMERSON ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802181014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034688844 | ||||||||
| FaxNumber: | 3034688850 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 EMERSON ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802181014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034688844 | ||||||||
| FaxNumber: | 3034688850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUBLER | ||||||||
| AuthorizedOfficialFirstName: | KATIE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3034688844 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 27698 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.