Provider Demographics
NPI:1376657411
Name:DART, DOUGLAS JAY (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JAY
Last Name:DART
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 1:3895 UPHAM ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4651
Mailing Address - Country:US
Mailing Address - Phone:303-487-0834
Mailing Address - Fax:303-487-6932
Practice Address - Street 1:3895 UPHAM ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4651
Practice Address - Country:US
Practice Address - Phone:303-487-0834
Practice Address - Fax:303-487-6932
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27383174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01273838Medicaid
COE90278Medicare UPIN
CO01273838Medicaid