Provider Demographics
NPI:1174663140
Name:MAROLDO, AMY SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:SUSAN
Last Name:MAROLDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:SUSAN
Other - Last Name:EKSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4419 CENTENNIAL BLVD
Mailing Address - Street 2:#244
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-3739
Mailing Address - Country:US
Mailing Address - Phone:719-963-4170
Mailing Address - Fax:719-548-0338
Practice Address - Street 1:175 S. UNION BLVD.
Practice Address - Street 2:SUITE 305
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3126
Practice Address - Country:US
Practice Address - Phone:719-365-6881
Practice Address - Fax:719-365-6877
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28328207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COMA28328OtherBLUE SHIELD
CO01283282Medicaid
COMA28328OtherBLUE SHIELD
COCOAAA2753Medicare PIN
CO804269Medicare PIN