Provider Demographics
NPI:1306886114
Name:MOUNTAIN VIEW DERMATOLOGY PC
Entity type:Organization
Organization Name:MOUNTAIN VIEW DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-485-5200
Mailing Address - Street 1:3464 S WILLOW ST
Mailing Address - Street 2:SUITE 068
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80231-4531
Mailing Address - Country:US
Mailing Address - Phone:303-755-2900
Mailing Address - Fax:303-755-0404
Practice Address - Street 1:2935 BASELINE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2366
Practice Address - Country:US
Practice Address - Phone:303-485-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04023727Medicaid