Provider Demographics
NPI:1386652550
Name:RABOLD, JAMES GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GREGORY
Last Name:RABOLD
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 1:341 PALOMINO WAY
Mailing Address - Street 2:PO BOX 455
Mailing Address - City:CRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:81131
Mailing Address - Country:US
Mailing Address - Phone:719-256-4628
Mailing Address - Fax:719-256-4628
Practice Address - Street 1:7401 CHURCH RANCH BLVD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80021
Practice Address - Country:US
Practice Address - Phone:303-282-4015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01218197Medicaid
COE23999Medicare UPIN
CO319798Medicare ID - Type Unspecified