Provider Demographics
NPI:1528022134
Name:LIOTTA, FERDINAND JESUS (MD)
Entity Type:Individual
Prefix:
First Name:FERDINAND
Middle Name:JESUS
Last Name:LIOTTA
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 1:1450 E VALLEY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-8304
Mailing Address - Country:US
Mailing Address - Phone:970-927-8611
Mailing Address - Fax:970-927-8633
Practice Address - Street 1:1450 E VALLEY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-8304
Practice Address - Country:US
Practice Address - Phone:970-927-8611
Practice Address - Fax:970-927-8633
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35451207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1354513Medicaid
CO1354513Medicaid
39234Medicare PIN