Provider Demographics
NPI:1548758964
Name:DENVER CLINIC
Entity Type:Organization
Organization Name:DENVER CLINIC
Other - Org Name:CLINICA DENVER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAURICIO
Authorized Official - Middle Name:LUDER
Authorized Official - Last Name:WAINTRUB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-337-5575
Mailing Address - Street 1:1360 S POTOMAC ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-4505
Mailing Address - Country:US
Mailing Address - Phone:303-337-5575
Mailing Address - Fax:303-745-6264
Practice Address - Street 1:1525 RALEIGH ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204
Practice Address - Country:US
Practice Address - Phone:303-433-2565
Practice Address - Fax:303-745-6264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13037366Medicaid