Basic Information
| Provider Information | |||||||||
| NPI: | 1316968209 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KY SAWADA MD PROFESSIONAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3464 S WILLOW ST | ||||||||
| Address2: | SUITE 657 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802314531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037552900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 INDIANA ST | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804015027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034639600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 06/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | SAWADA | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3034639600 | ||||||||
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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 | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | SW28118 | 01 | CO | BLUE SHIELD | OTHER | DA4475 | 01 | CO | RAILROAD MEDICARE | OTHER |