Provider Demographics
NPI:1508979519
Name:IKELHEIMER, DOUGLAS MARK (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:MARK
Last Name:IKELHEIMER
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 1:777 BANNOCK ST
Mailing Address - Street 2:MC 7782
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:777 BANNOCK ST
Practice Address - Street 2:MC 7782
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4507
Practice Address - Country:US
Practice Address - Phone:303-436-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO403532084P0800X
PAMD4534782084P0800X, 2084P0802X
WI768222084P0800X
VA01012595752084P0800X, 2084P0802X, 2084N0400X
CAC1638162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05722730Medicaid
I21980Medicare UPIN
CO800365Medicare ID - Type Unspecified