Provider Demographics
NPI:1588972301
Name:PUEBLO PEDIATRICS, LLC
Entity type:Organization
Organization Name:PUEBLO PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:QUAZI
Authorized Official - Middle Name:R
Authorized Official - Last Name:PARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-404-3665
Mailing Address - Street 1:200 S SANTA FE AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-4270
Mailing Address - Country:US
Mailing Address - Phone:719-296-5842
Mailing Address - Fax:719-542-0746
Practice Address - Street 1:900 INDIANA AVE
Practice Address - Street 2:SUITE D
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3766
Practice Address - Country:US
Practice Address - Phone:719-404-3672
Practice Address - Fax:719-564-0374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43488208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO88981541Medicaid
CO1851378749OtherNPI INDIVIDUAL