Provider Demographics
NPI:1265993679
Name:MEJIA, DANIEL (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:MEJIA
Suffix:
Gender:M
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:PO BOX 9049
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-9049
Mailing Address - Country:US
Mailing Address - Phone:303-415-8940
Mailing Address - Fax:
Practice Address - Street 1:3 SUPERIOR DR STE 100B
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:CO
Practice Address - Zip Code:80027-8653
Practice Address - Country:US
Practice Address - Phone:303-415-8940
Practice Address - Fax:303-425-9259
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK192062207Q00000X
CODR.0073770207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1732943Medicaid