Provider Demographics
NPI:1922351279
Name:INFECTIOUS DISEASE SPECIALIST OF SOUTHERN COLORADO, PLLC
Entity Type:Organization
Organization Name:INFECTIOUS DISEASE SPECIALIST OF SOUTHERN COLORADO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:NWANGUMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-582-8425
Mailing Address - Street 1:PO BOX 470238
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80047-0238
Mailing Address - Country:US
Mailing Address - Phone:719-582-8425
Mailing Address - Fax:888-719-1380
Practice Address - Street 1:2001 LAKE AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3538
Practice Address - Country:US
Practice Address - Phone:719-582-8425
Practice Address - Fax:888-719-1380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2023-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR51262261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
1336601387OtherNPI