Provider Demographics
NPI:1114034550
Name:HAVERLY, STEPHEN SAMUEL
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:SAMUEL
Last Name:HAVERLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:STEPHEN
Other - Middle Name:S
Other - Last Name:HAVERLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 17752
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-0752
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1010 THREE SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8296
Practice Address - Country:US
Practice Address - Phone:303-306-7783
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42845207P00000X
CAA77557207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33457271Medicaid
COP00678278OtherPAILROAD MEDICARE PIN
NM77988230Medicaid
CA00A775570Medicaid
COCO300000Medicare PIN
CA00A775570Medicaid