Provider Demographics
NPI:1588817464
Name:BOULDER ENDOCRINOLOGY PHYSICIANS
Entity Type:Organization
Organization Name:BOULDER ENDOCRINOLOGY PHYSICIANS
Other - Org Name:BOULDER ENDOCRINOLOGY PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANDAGERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-586-5200
Mailing Address - Street 1:892 W SOUTH BOULDER RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-2453
Mailing Address - Country:US
Mailing Address - Phone:303-586-5200
Mailing Address - Fax:303-586-5201
Practice Address - Street 1:892 W SOUTH BOULDER RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-2453
Practice Address - Country:US
Practice Address - Phone:303-586-5200
Practice Address - Fax:303-586-5201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45001207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO81287895Medicaid
COCOB4320Medicare PIN