Basic Information
| Provider Information | |||||||||
| NPI: | 1659791994 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY OF PUEBLO, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1925 E ORMAN AVE STE A340 | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810043571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195697400 | ||||||||
| FaxNumber: | 7195697338 | ||||||||
| 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: | 04/25/2014 | ||||||||
| LastUpdateDate: | 06/08/2020 | ||||||||
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| AuthorizedOfficialLastName: | FELIZ | ||||||||
| AuthorizedOfficialFirstName: | ANTONIO | ||||||||
| AuthorizedOfficialMiddleName: | PADILLA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7195697400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | DR.0037048 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 82981035 | 05 | CO | MEDICAID |