Provider Demographics
NPI:1295894178
Name:BOULDER WOMENS CARE PC
Entity type:Organization
Organization Name:BOULDER WOMENS CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAKO
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIMODA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-441-0587
Mailing Address - Street 1:PO BOX 17458
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80308-0458
Mailing Address - Country:US
Mailing Address - Phone:303-441-0587
Mailing Address - Fax:303-996-0801
Practice Address - Street 1:311 MAPLETON AVE # 100
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3979
Practice Address - Country:US
Practice Address - Phone:303-441-0587
Practice Address - Fax:303-996-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO56795207V00000X
CO36257207V00000X
CO34690207V00000X
CO43546207V00000X
CO42614207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO23028327Medicaid
CO80637779Medicaid
CO01346907Medicaid
CO55404251Medicaid
G11843Medicare UPIN
I03942Medicare UPIN
CO55404251Medicaid
G21386Medicare UPIN
COC441158Medicare PIN