Provider Demographics
NPI:1710246087
Name:VANOOTEGHEM, STEPHEN GRANT (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:GRANT
Last Name:VANOOTEGHEM
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 351750
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80035-1750
Mailing Address - Country:US
Mailing Address - Phone:303-484-8404
Mailing Address - Fax:
Practice Address - Street 1:8300 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6005
Practice Address - Country:US
Practice Address - Phone:303-425-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0056397207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO502284YPB5Medicare PIN