Provider Demographics
NPI:1710129473
Name:THOMPSON, BREANNA SUMMERS (DO)
Entity Type:Individual
Prefix:DR
First Name:BREANNA
Middle Name:SUMMERS
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:MARIE
Other - Last Name:SUMMERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-286-4560
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:1635 BLUE SPRUCE DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-5427
Practice Address - Country:US
Practice Address - Phone:970-494-4040
Practice Address - Fax:970-494-4076
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0049522208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71333240Medicaid
COCOA108571Medicare PIN