Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 46383 | CO |
N | 207R00000X | Internist | 46383 | CO |
N | 111NI0900X | Internist | 46383 | CO |
N | 207RA0201X | Internist - Allergy & Immunology | MD044657E | PA |
NPI | 1417983438 |
---|---|
Provider Name | Mark David Menich |
First Address | Boulder, CO 80304-1104 |
Second Address | Boulder, CO 80304-1104 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2006 |
Last Update Date | 30/12/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
14209764 | (05) | CO |