Provider Demographics
NPI:1912062746
Name:SOESILO, IRENE S (DO)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:S
Last Name:SOESILO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5600 S QUEBEC STREET
Mailing Address - Street 2:SUITE 312A
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-2208
Mailing Address - Country:US
Mailing Address - Phone:720-754-2296
Mailing Address - Fax:844-669-1725
Practice Address - Street 1:1719 E 19TH AVE
Practice Address - Street 2:IM HOSPITALIST
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1235
Practice Address - Country:US
Practice Address - Phone:720-754-2296
Practice Address - Fax:844-669-1725
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO43413207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10722238Medicaid
CO10722238Medicaid
COCOA108984Medicare PIN
COP01129468Medicare PIN