Provider Demographics
NPI:1114030533
Name:CHIAVETTA, THOMAS G (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:CHIAVETTA
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 1:2121 E HARMONY RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-482-6456
Mailing Address - Fax:970-482-3921
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:SUITE 250
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3400
Practice Address - Country:US
Practice Address - Phone:970-482-6456
Practice Address - Fax:970-482-3921
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26334208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01263342Medicaid
CH02258Medicare ID - Type Unspecified
D24789Medicare UPIN