Provider Demographics
NPI:1417055070
Name:IANNOTTI, MICHAEL ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:IANNOTTI
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 1:150 OLD LARAMIE TRL E
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-7018
Mailing Address - Country:US
Mailing Address - Phone:720-773-1352
Mailing Address - Fax:303-604-6958
Practice Address - Street 1:150 OLD LARAMIE TRL E
Practice Address - Street 2:SUITE 210
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-7018
Practice Address - Country:US
Practice Address - Phone:720-773-1352
Practice Address - Fax:303-604-6958
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0039567207Q00000X
COCO39567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COI01828Medicare UPIN
CO524538Medicare PIN
COI01828Medicare UPIN
CO524538Medicare PIN