Provider Demographics
NPI:1356771802
Name:MARY G HEYROSA MD LLC
Entity type:Organization
Organization Name:MARY G HEYROSA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:HEYROSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-483-5690
Mailing Address - Street 1:757 E 20TH AVE
Mailing Address - Street 2:STE 370 #444
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-3278
Mailing Address - Country:US
Mailing Address - Phone:720-483-5690
Mailing Address - Fax:
Practice Address - Street 1:157 STEELE ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-8020
Practice Address - Country:US
Practice Address - Phone:720-575-9300
Practice Address - Fax:720-575-9566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-20
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0044751174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO85929760Medicaid
346166Medicare UPIN