Provider Demographics
NPI:1598799314
Name:HURST, JOHN GORDON (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GORDON
Last Name:HURST
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:PO BOX 337420
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80633-0624
Mailing Address - Country:US
Mailing Address - Phone:970-663-2742
Mailing Address - Fax:970-667-0847
Practice Address - Street 1:1801 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5154
Practice Address - Country:US
Practice Address - Phone:970-679-9349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22264174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO930005396OtherRAILROAD MEDICARE
CO01222645Medicaid
COD24066Medicare UPIN
CO930005396OtherRAILROAD MEDICARE