Provider Demographics
NPI:1184982621
Name:JOHN, PREMOD JAMES (MD)
Entity type:Individual
Prefix:
First Name:PREMOD
Middle Name:JAMES
Last Name:JOHN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:9135 S RIDGELINE BLVD
Mailing Address - Street 2:STE 190
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-2395
Mailing Address - Country:US
Mailing Address - Phone:303-649-3140
Mailing Address - Fax:303-649-3154
Practice Address - Street 1:9135 S RIDGELINE BLVD
Practice Address - Street 2:STE 190
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-2395
Practice Address - Country:US
Practice Address - Phone:303-649-3140
Practice Address - Fax:303-649-3154
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2024-04-24
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Provider Licenses
StateLicense IDTaxonomies
CO55747207Q00000X
TXT5751207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO446506YLTTOtherMEDICARE PTAN
CO77780094Medicaid