Provider Demographics
NPI:1316572803
Name:COLORADO RETINA ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:COLORADO RETINA ASSOCIATES, PLLC
Other - Org Name:COLORADO RETINA ASSOCIATES, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KYLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAKASUGI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-261-1600
Mailing Address - Street 1:PO BOX 17949
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-0949
Mailing Address - Country:US
Mailing Address - Phone:303-261-1600
Mailing Address - Fax:303-261-1601
Practice Address - Street 1:360 PEAK ONE DR STE 300
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-5948
Practice Address - Country:US
Practice Address - Phone:303-261-1600
Practice Address - Fax:303-261-1601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO RETINA ASSOCIATES, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-05
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207WX0108XAllopathic & Osteopathic PhysiciansOphthalmologyUveitis and Ocular Inflammatory DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000146494Medicaid
CO74505807Medicaid
CO9000165843Medicaid
CO9000171077Medicaid
CO9000190491Medicaid
CO9000197544Medicaid