Provider Demographics
NPI:1003892761
Name:ALLEN, MICHAEL W (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:BILLING DEPT - CREDENTIALIST
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-286-4560
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:220 E ROGERS RD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6027
Practice Address - Country:US
Practice Address - Phone:303-776-3250
Practice Address - Fax:303-682-9269
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0041745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO29759331Medicaid
CO29759331Medicaid