Provider Demographics
NPI:1225525132
Name:PUEBLO SPORTS AND FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:PUEBLO SPORTS AND FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOSLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-544-2740
Mailing Address - Street 1:1315 FORTINO BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1981
Mailing Address - Country:US
Mailing Address - Phone:719-544-2740
Mailing Address - Fax:
Practice Address - Street 1:1315 FORTINO BLVD STE C
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1981
Practice Address - Country:US
Practice Address - Phone:719-544-2740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2018-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO543004207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0004910OtherPA NUMBER
CO1268788Medicaid