Provider Demographics
NPI:1518917392
Name:MARUYAMA, GEN J (MD)
Entity Type:Individual
Prefix:
First Name:GEN
Middle Name:J
Last Name:MARUYAMA
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 223897
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15251-2897
Mailing Address - Country:US
Mailing Address - Phone:720-501-5000
Mailing Address - Fax:303-458-3997
Practice Address - Street 1:11600 W 2ND PL
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1527
Practice Address - Country:US
Practice Address - Phone:720-321-0000
Practice Address - Fax:720-321-1621
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA624952085R0202X
CO449072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO40906370Medicaid
CO40906370Medicaid
COC806473Medicare PIN
COC806474Medicare PIN
COP00369517Medicare PIN