Provider Demographics
NPI:1548441611
Name:COLUMBINE RIDGE FAMILY MEDICINE P C
Entity type:Organization
Organization Name:COLUMBINE RIDGE FAMILY MEDICINE P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHARE HOLDER/ DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:GUSTAVO
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-875-8198
Mailing Address - Street 1:965 PLATTE RIVER BLVD
Mailing Address - Street 2:UNIT O, BLDG 1
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-4353
Mailing Address - Country:US
Mailing Address - Phone:303-655-9866
Mailing Address - Fax:303-655-9869
Practice Address - Street 1:965 PLATTE RIVER BLVD
Practice Address - Street 2:UNIT O BLDG 1
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-4353
Practice Address - Country:US
Practice Address - Phone:303-655-9866
Practice Address - Fax:303-655-9869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36368207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC803931Medicare PIN