Provider Demographics
NPI:1821693623
Name:MBASI BELEKWA, JEAN MAURICE
Entity Type:Individual
Prefix:
First Name:JEAN MAURICE
Middle Name:
Last Name:MBASI BELEKWA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 S SALIDA WAY
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-4186
Mailing Address - Country:US
Mailing Address - Phone:720-628-0309
Mailing Address - Fax:
Practice Address - Street 1:2450 S SALIDA WAY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013-4186
Practice Address - Country:US
Practice Address - Phone:720-628-0309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03-099-0670Medicaid