Provider Demographics
NPI:1740350438
Name:WAMBOLDT, FREDERICK S (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:S
Last Name:WAMBOLDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-2761
Mailing Address - Country:US
Mailing Address - Phone:303-388-4461
Mailing Address - Fax:303-270-2174
Practice Address - Street 1:1400 JACKSON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-2761
Practice Address - Country:US
Practice Address - Phone:303-388-4461
Practice Address - Fax:303-270-2174
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO296802084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01296805Medicaid
COJ6644Medicare PIN
COB94322Medicare UPIN