Provider Demographics
NPI:1306823091
Name:LONGENECKER, BETSY (MD)
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:
Last Name:LONGENECKER
Suffix:
Gender:F
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:PO BOX 62
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-0062
Mailing Address - Country:US
Mailing Address - Phone:970-298-2273
Mailing Address - Fax:970-298-1809
Practice Address - Street 1:2698 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8818
Practice Address - Country:US
Practice Address - Phone:970-298-2800
Practice Address - Fax:970-298-6291
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01281443Medicaid
CO01281443Medicaid
COC322118Medicare PIN