Provider Demographics
NPI:1376671628
Name:SOUTH DENVER INTERNAL MEDICINE AND PEDIATRICS, P.C.
Entity Type:Organization
Organization Name:SOUTH DENVER INTERNAL MEDICINE AND PEDIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-799-8890
Mailing Address - Street 1:10103 RIDGEGATE PKWY
Mailing Address - Street 2:SUITE 114
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5520
Mailing Address - Country:US
Mailing Address - Phone:303-799-8890
Mailing Address - Fax:303-799-8891
Practice Address - Street 1:10103 RIDGEGATE PKWY
Practice Address - Street 2:SUITE 114
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5520
Practice Address - Country:US
Practice Address - Phone:303-799-8890
Practice Address - Fax:303-799-8891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33478261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
C506878Medicare PIN