Provider Demographics
NPI:1518590702
Name:BASOW, JUDITH M
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:M
Last Name:BASOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 ARCTIC FOX DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3536
Mailing Address - Country:US
Mailing Address - Phone:970-689-4419
Mailing Address - Fax:
Practice Address - Street 1:3825 ARCTIC FOX DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3536
Practice Address - Country:US
Practice Address - Phone:970-689-4419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0000622208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation