Provider Demographics
NPI:1134130073
Name:PRZYSTUP, PAUL DEAN (DPM)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DEAN
Last Name:PRZYSTUP
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 RUSHMORE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81507-4016
Mailing Address - Country:US
Mailing Address - Phone:970-270-7541
Mailing Address - Fax:
Practice Address - Street 1:2121 NORTH AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6428
Practice Address - Country:US
Practice Address - Phone:970-242-0731
Practice Address - Fax:970-263-5094
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO482213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01004829Medicaid
CO507468Medicare ID - Type Unspecified
CO01004829Medicaid