Provider Demographics
NPI:1538125083
Name:BOUSTRED, ALLISTER M (MD)
Entity Type:Individual
Prefix:
First Name:ALLISTER
Middle Name:M
Last Name:BOUSTRED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 E HARMONY RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-8620
Mailing Address - Country:US
Mailing Address - Phone:970-493-8800
Mailing Address - Fax:970-498-8800
Practice Address - Street 1:2315 E HARMONY RD
Practice Address - Street 2:SUITE 160
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-8620
Practice Address - Country:US
Practice Address - Phone:970-493-8800
Practice Address - Fax:970-498-8800
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO45791208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87736730Medicaid
COH49578Medicare UPIN
COCO301503Medicare PIN
H49578Medicare UPIN