Provider Demographics
NPI:1861743379
Name:FIALLOS, LIA A (DO)
Entity type:Individual
Prefix:
First Name:LIA
Middle Name:A
Last Name:FIALLOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 CHAMPA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-2529
Mailing Address - Country:US
Mailing Address - Phone:303-312-2217
Mailing Address - Fax:
Practice Address - Street 1:2130 STOUT ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-2827
Practice Address - Country:US
Practice Address - Phone:303-293-2220
Practice Address - Fax:303-296-8826
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11128880-1204207Q00000X
WI66304-21207Q00000X, 207V00000X
CODR0053715207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400334944Medicare PIN