Provider Demographics
NPI:1417128455
Name:CENTRAL COLORADO DERMATOLOGY, P.C.
Entity Type:Organization
Organization Name:CENTRAL COLORADO DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:TIMKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-539-4600
Mailing Address - Street 1:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-0849
Mailing Address - Country:US
Mailing Address - Phone:719-539-4600
Mailing Address - Fax:719-539-4629
Practice Address - Street 1:925 RUSH DR
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-9665
Practice Address - Country:US
Practice Address - Phone:719-539-4600
Practice Address - Fax:719-539-4629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39785207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO35180846Medicaid
CO457538Medicare UPIN