Provider Demographics
NPI:1699092221
Name:SUROVIK, JAMIE (MD)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:SUROVIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12645 E EUCLID DR
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80111-6437
Mailing Address - Country:US
Mailing Address - Phone:303-493-1910
Mailing Address - Fax:303-493-1915
Practice Address - Street 1:12645 E EUCLID DR
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80111-6437
Practice Address - Country:US
Practice Address - Phone:303-493-1910
Practice Address - Fax:303-493-1915
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO48670207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68171315Medicaid
CO48670OtherSTATE MEDICAL LICENSE