Basic Information
| Provider Information | |||||||||
| NPI: | 1538165691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FELIZ | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | PADILLA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3510 SAN JOSE CT | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810053916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195459713 | ||||||||
| FaxNumber: | 7195452054 | ||||||||
| Practice Location | |||||||||
| Address1: | 1925 E ORMAN AVE STE A340 | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810043571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195697400 | ||||||||
| FaxNumber: | 7195697338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 06/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 37048 | CO | N | Other Service Providers | Specialist | 208800000X | 37048 | CO | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 01370485 | 05 | CO | MEDICAID |