Provider Demographics
NPI:1396858650
Name:PETTINE, STEFAN M (MD)
Entity Type:Individual
Prefix:
First Name:STEFAN
Middle Name:M
Last Name:PETTINE
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 1:2121 E HARMONY RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-482-6456
Mailing Address - Fax:970-482-3921
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:SUITE 250
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3400
Practice Address - Country:US
Practice Address - Phone:970-482-6456
Practice Address - Fax:970-482-3921
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39045208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15572358Medicaid
CO15572358Medicaid
285228Medicare ID - Type Unspecified