Provider Demographics
NPI:1932101490
Name:IMOLA, MARIO J (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:J
Last Name:IMOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3600 S LOGAN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3766
Mailing Address - Country:US
Mailing Address - Phone:303-839-7980
Mailing Address - Fax:303-839-7936
Practice Address - Street 1:3600 S LOGAN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-3766
Practice Address - Country:US
Practice Address - Phone:303-839-7980
Practice Address - Fax:303-839-7936
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO38335207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO841553144OtherTAX ID
WY117142900Medicaid
CO95739831Medicaid
COG11247Medicare UPIN
CO95739831Medicaid
CO37821Medicare ID - Type Unspecified