Provider Demographics
NPI:1114187648
Name:MESA, JODIE KAY (DO)
Entity Type:Individual
Prefix:DR
First Name:JODIE
Middle Name:KAY
Last Name:MESA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JODIE
Other - Middle Name:KAY
Other - Last Name:HAMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:8540 SCARBOROUGH DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7502
Mailing Address - Country:US
Mailing Address - Phone:719-955-4200
Mailing Address - Fax:719-365-7667
Practice Address - Street 1:8540 SCARBOROUGH DR
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7502
Practice Address - Country:US
Practice Address - Phone:719-955-4200
Practice Address - Fax:719-365-7667
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-9579207Q00000X
CODR-54111207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58052348Medicaid
CO58052348Medicaid