Provider Demographics
NPI:1093986986
Name:WESTERN OTOLARYNGOLOGY
Entity Type:Organization
Organization Name:WESTERN OTOLARYNGOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:FETZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-425-0449
Mailing Address - Street 1:3550 LUTHERAN PKWY W
Mailing Address - Street 2:STE 102 B
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6013
Mailing Address - Country:US
Mailing Address - Phone:303-425-0449
Mailing Address - Fax:
Practice Address - Street 1:3550 LUTHERAN PKWY W
Practice Address - Street 2:STE 102
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6013
Practice Address - Country:US
Practice Address - Phone:303-425-0449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19871416289207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC86104Medicare PIN