Basic Information
| Provider Information | |||||||||
| NPI: | 1407993132 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGESTIVE DISEASE ENDOSCOPY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 N WEBER ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194736115 | ||||||||
| FaxNumber: | 7194733688 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 N WEBER ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194736115 | ||||||||
| FaxNumber: | 7194733688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHAFII | ||||||||
| AuthorizedOfficialFirstName: | ABBASS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7194736115 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 1236 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1236 | 01 | CO | STATE LICENSE | OTHER |