Basic Information
| Provider Information | |||||||||
| NPI: | 1528163979 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN DER SLOOT | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 S MONACO ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802373487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035848000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 E HAMPDEN AVE STE 225 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037889200 | ||||||||
| FaxNumber: | 3037814368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 21280 | WV | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207YX0007X | 252522 | NY | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
| ID | Type | State | Issuer | Description | 1809555000 | 05 | WV | MEDICAID | 03117264 | 05 | NY | MEDICAID |