Provider Demographics
NPI:1255477790
Name:ABBOTT, JOHN PHILLIP (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PHILLIP
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 KENDALL DR
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:CO
Mailing Address - Zip Code:81052-3939
Mailing Address - Country:US
Mailing Address - Phone:719-336-0261
Mailing Address - Fax:719-336-0265
Practice Address - Street 1:302 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WILEY
Practice Address - State:CO
Practice Address - Zip Code:81092
Practice Address - Country:US
Practice Address - Phone:719-829-4286
Practice Address - Fax:719-829-4288
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01293463Medicaid
E67152Medicare UPIN