Provider Demographics
NPI:1447753678
Name:ROTA, GARRETT WAYNE (DO)
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:WAYNE
Last Name:ROTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1000 S BROADWAY APT 237
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-4095
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2485 E PIKES PEAK AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-6004
Practice Address - Country:US
Practice Address - Phone:719-634-2001
Practice Address - Fax:719-634-2211
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0067795207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program