Provider Demographics
NPI:1396389680
Name:RETINA CONSULTANTS OF SOUTHERN COLORADO P C
Entity Type:Organization
Organization Name:RETINA CONSULTANTS OF SOUTHERN COLORADO P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SUNDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPOBIANCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-473-9595
Mailing Address - Street 1:2770 N UNION BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1183
Mailing Address - Country:US
Mailing Address - Phone:719-473-9595
Mailing Address - Fax:719-227-0669
Practice Address - Street 1:2770 N UNION BLVD STE 140
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1183
Practice Address - Country:US
Practice Address - Phone:719-473-9595
Practice Address - Fax:719-227-0669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-30
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1013250240Medicaid
CO67174787Medicaid
CO9000173749Medicaid
CO97656372Medicaid
CO01280791Medicaid
CO93008716Medicaid