Provider Demographics
NPI:1558482125
Name:DERN, SUSAN GABRIELLE (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:GABRIELLE
Last Name:DERN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4036
Mailing Address - Fax:970-490-4378
Practice Address - Street 1:2502 E PIKES PEAK AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-6033
Practice Address - Country:US
Practice Address - Phone:719-365-6840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01295732Medicaid
COE85537Medicare ID - Type Unspecified
CO01295732Medicaid