Provider Demographics
NPI:1164499976
Name:IMLAY, LONNIE L (MD)
Entity Type:Individual
Prefix:DR
First Name:LONNIE
Middle Name:L
Last Name:IMLAY
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 1:1925 E. ORMAN AVE.
Mailing Address - Street 2:SUITE A109
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004
Mailing Address - Country:US
Mailing Address - Phone:719-564-0210
Mailing Address - Fax:719-564-9483
Practice Address - Street 1:1925 E. ORMAN AVE.
Practice Address - Street 2:SUITE A109
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004
Practice Address - Country:US
Practice Address - Phone:719-564-0210
Practice Address - Fax:719-564-9483
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA29224208600000X
CO44366208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45707731Medicaid
CO45707731Medicaid