Basic Information
| Provider Information | |||||||||
| NPI: | 1306886114 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN VIEW DERMATOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3464 S WILLOW ST | ||||||||
| Address2: | SUITE 068 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802314531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037552900 | ||||||||
| FaxNumber: | 3037550404 | ||||||||
| Practice Location | |||||||||
| Address1: | 2935 BASELINE RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803032366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034855200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 04/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | LEVINE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3034855200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 04023727 | 05 | CO | MEDICAID |