Provider Demographics
NPI:1699009084
Name:MOUNTAIN BLUE CANCER CARE CENTER PC
Entity Type:Organization
Organization Name:MOUNTAIN BLUE CANCER CARE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:E
Authorized Official - Last Name:WITTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-788-8675
Mailing Address - Street 1:799 E HAMPDEN AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-2777
Mailing Address - Country:US
Mailing Address - Phone:303-788-8675
Mailing Address - Fax:303-788-8489
Practice Address - Street 1:799 E HAMPDEN AVE STE 500
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2777
Practice Address - Country:US
Practice Address - Phone:303-788-8675
Practice Address - Fax:303-788-8489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39764207RH0003X
COCO39762207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO82076529Medicaid
COCOB4870Medicare PIN