Provider Demographics
NPI:1801870530
Name:IMIG, JOHN R (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:IMIG
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 1:4745 ARAPAHOE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1080
Mailing Address - Country:US
Mailing Address - Phone:303-938-4710
Mailing Address - Fax:
Practice Address - Street 1:4745 ARAPAHOE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1080
Practice Address - Country:US
Practice Address - Phone:303-938-4710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17514207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D23292Medicare UPIN
CO12068Medicare ID - Type Unspecified