Provider Demographics
NPI:1235176546
Name:GROTH, BRYAN ALAN (DPM)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ALAN
Last Name:GROTH
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 1:455 E PIKES PEAK AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3648
Mailing Address - Country:US
Mailing Address - Phone:719-475-8080
Mailing Address - Fax:719-475-0913
Practice Address - Street 1:455 E PIKES PEAK AVE STE 220
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3673
Practice Address - Country:US
Practice Address - Phone:719-475-8080
Practice Address - Fax:719-475-0913
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO593213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO85559075Medicaid
COC437168Medicare PIN
CO85559075Medicaid