Provider Demographics
NPI:1427006139
Name:FROGOZO, MARIOVISTO F (MD)
Entity Type:Individual
Prefix:
First Name:MARIOVISTO
Middle Name:F
Last Name:FROGOZO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 668
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80001-0668
Mailing Address - Country:US
Mailing Address - Phone:303-422-9438
Mailing Address - Fax:
Practice Address - Street 1:800 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4212
Practice Address - Country:US
Practice Address - Phone:970-249-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41866207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO83133062Medicaid
COC805463Medicare PIN
COI00571Medicare UPIN