Provider Demographics
NPI:1417983438
Name:MENICH, MARK DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:MENICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3950 BROADWAY ST
Mailing Address - Street 2:BOULDER VALLEY ASTHMA AND ALLERGY CLINICS
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-1104
Mailing Address - Country:US
Mailing Address - Phone:303-444-5995
Mailing Address - Fax:303-443-5030
Practice Address - Street 1:3950 BROADWAY ST
Practice Address - Street 2:BOULDER VALLEY ASTHMA AND ALLERGY CLINICS
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-1104
Practice Address - Country:US
Practice Address - Phone:303-444-5995
Practice Address - Fax:303-443-5030
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO46383207KA0200X, 207R00000X
PAMD044657E207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO14209764Medicaid
COCO305418Medicare PIN