Provider Demographics
NPI:1285632893
Name:REPPERT, JAMES FRED (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:FRED
Last Name:REPPERT
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 1:1335 PHAY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2349
Mailing Address - Country:US
Mailing Address - Phone:719-275-4151
Mailing Address - Fax:719-275-3743
Practice Address - Street 1:1335 PHAY AVE STE A
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2349
Practice Address - Country:US
Practice Address - Phone:719-275-4151
Practice Address - Fax:719-275-3743
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
CO22797207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CORE75491OtherBLUE CROSS OF COLORADO
CO01227974Medicaid
CO01227974Medicaid
COC397218Medicare PIN