Provider Demographics
NPI:1558463307
Name:DEMIDOVICH, CARL W (MD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:W
Last Name:DEMIDOVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:950 E HARVARD AVE
Mailing Address - Street 2:STE 440
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-7009
Mailing Address - Country:US
Mailing Address - Phone:303-744-2704
Mailing Address - Fax:303-744-3244
Practice Address - Street 1:950 E HARVARD AVE
Practice Address - Street 2:STE 440
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-7009
Practice Address - Country:US
Practice Address - Phone:303-744-2704
Practice Address - Fax:303-744-3244
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO33910207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO19292OtherBCBS
CO01339100Medicaid
CO84-1511239OtherFEDERAL TAX ID
CO070015071OtherRR MEDICARE
CO070015071OtherRR MEDICARE
CO84-1511239OtherFEDERAL TAX ID