Provider Demographics
NPI:1326047143
Name:COLORADO OTOLARYNGOLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:COLORADO OTOLARYNGOLOGY ASSOCIATES, LLC
Other - Org Name:COLORADO ENT & ALLERGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-867-7800
Mailing Address - Street 1:PO BOX 9190
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80932-0190
Mailing Address - Country:US
Mailing Address - Phone:719-867-7800
Mailing Address - Fax:719-867-7899
Practice Address - Street 1:3030 N CIRCLE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1177
Practice Address - Country:US
Practice Address - Phone:719-867-7800
Practice Address - Fax:719-867-7899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04021713Medicaid
CO04021713Medicaid