Basic Information
| Provider Information | |||||||||
| NPI: | 1336132638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERSOFF | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 E HARVARD AVE | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802107009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038710977 | ||||||||
| FaxNumber: | 3037332387 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 E HARVARD AVE | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802107009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038710977 | ||||||||
| FaxNumber: | 3037332387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 16080 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 01160803 | 05 | CO | MEDICAID |