Provider Demographics
NPI:1871182444
Name:COLORADO RETINA ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:COLORADO RETINA ASSOCIATES, PLLC
Other - Org Name:COLORADO RETINA ASSOCIATES, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIAL SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KYLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAKASUGI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-261-1600
Mailing Address - Street 1:PO BOX 17949
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-0949
Mailing Address - Country:US
Mailing Address - Phone:303-261-1600
Mailing Address - Fax:303-261-1601
Practice Address - Street 1:255 S ROUTT ST STE 200
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-2271
Practice Address - Country:US
Practice Address - Phone:303-261-1600
Practice Address - Fax:303-261-1601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO RETINA ASSOCIATES, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-18
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000190491Medicaid