Provider Demographics
NPI:1619940459
Name:BYNUM, GAITHER D (MD)
Entity Type:Individual
Prefix:
First Name:GAITHER
Middle Name:D
Last Name:BYNUM
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 1:2635 N 7TH ST STE 4205
Mailing Address - Street 2:PO BOX 62
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8209
Mailing Address - Country:US
Mailing Address - Phone:970-298-7049
Mailing Address - Fax:970-298-2079
Practice Address - Street 1:2635 N 7TH ST STE 4205
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8209
Practice Address - Country:US
Practice Address - Phone:970-298-7049
Practice Address - Fax:970-298-2079
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45316207R00000X
CO44569207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO66835216Medicaid
WI34471400Medicaid
COC806151Medicare PIN
WI34471400Medicaid