Provider Demographics
NPI:1467451583
Name:ROBERTS, AVA J (PODIATRIST DPM)
Entity Type:Individual
Prefix:
First Name:AVA
Middle Name:J
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PODIATRIST DPM
Other - Prefix:
Other - First Name:AVA
Other - Middle Name:J
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 S UNION BLVD STE 305
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3126
Practice Address - Country:US
Practice Address - Phone:719-365-6881
Practice Address - Fax:719-365-6877
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1188213E00000X
PASC004676R213E00000X
CO721213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64226778Medicaid
NM64226778Medicaid
8HAW53Medicare ID - Type Unspecified