Provider Demographics
NPI:1225162134
Name:JERRY K POPHAM, MD PC
Entity Type:Organization
Organization Name:JERRY K POPHAM, MD PC
Other - Org Name:PARK AVENUE OCULOPLASTIC SURGEONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:DUBLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-468-8844
Mailing Address - Street 1:1800 EMERSON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1014
Mailing Address - Country:US
Mailing Address - Phone:303-468-8844
Mailing Address - Fax:303-468-8850
Practice Address - Street 1:1800 EMERSON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1014
Practice Address - Country:US
Practice Address - Phone:303-468-8844
Practice Address - Fax:303-468-8850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27698174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC538788Medicare ID - Type Unspecified
KS772537Medicare PIN