Provider Demographics
NPI:1336125103
Name:ANSELL, JULIE (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:ANSELL
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 1:203 S ROLLIE AVE
Mailing Address - Street 2:BILLING DEPT/CREDENTIALIST
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-286-4560
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:1755 48TH ST STE 200
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2712
Practice Address - Country:US
Practice Address - Phone:303-415-7450
Practice Address - Fax:303-494-5265
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2018-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0042406207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO14380030Medicaid
COH72918Medicare UPIN
CO462467YL0XMedicare PIN
COC811035Medicare PIN