Provider Demographics
NPI:1417969684
Name:SQUICQUERO, DAVID M (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:SQUICQUERO
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 1:5133 SHAVANO CT
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-2583
Mailing Address - Country:US
Mailing Address - Phone:970-674-1201
Mailing Address - Fax:970-674-0221
Practice Address - Street 1:5133 SHAVANO CT
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-2583
Practice Address - Country:US
Practice Address - Phone:970-674-1201
Practice Address - Fax:970-674-0221
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO408622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO83176713Medicaid
CO800972Medicare ID - Type Unspecified
COA16179Medicare UPIN