Basic Information
| Provider Information | |||||||||
| NPI: | 1942293485 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MAO | ||||||||
| FirstName: | JIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42 GARDEN CTR | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800201730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034650401 | ||||||||
| FaxNumber: | 3034381351 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 BALSAM AVE | ||||||||
| Address2: | RADIOLOGY | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034402273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 41795 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | DR.0041795 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 96073721 | 05 | CO | MEDICAID |