Basic Information
| Provider Information | |||||||||
| NPI: | 1295864833 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKEWOOD MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 WADSWORTH BLVD | ||||||||
| Address2: | #17 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802145728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032381488 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2020 WADSWORTH BLVD | ||||||||
| Address2: | #17 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802145728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032381488 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BUI | ||||||||
| AuthorizedOfficialFirstName: | HAI | ||||||||
| AuthorizedOfficialMiddleName: | PHONG | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3032381488 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 33410 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 33410 | 01 | CO | STATE LISCENSE | OTHER | 01334101 | 05 | CO | MEDICAID |