Provider Demographics
NPI:1053323196
Name:BROOMER, AMY M (DO)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:BROOMER
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 1:755 MALETA LANE
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80108-7610
Mailing Address - Country:US
Mailing Address - Phone:303-688-6355
Mailing Address - Fax:303-688-6876
Practice Address - Street 1:755 MALETA LANE
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80108-7610
Practice Address - Country:US
Practice Address - Phone:303-688-6355
Practice Address - Fax:303-688-6876
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44275207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO805248Medicare ID - Type Unspecified
COI51631Medicare UPIN