Provider Demographics
NPI:1750314894
Name:EARHART, STEPHANIE RENE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENE
Last Name:EARHART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 W HWY 50
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-2238
Mailing Address - Country:US
Mailing Address - Phone:719-530-2022
Mailing Address - Fax:719-539-2065
Practice Address - Street 1:550 W HWY 50
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2238
Practice Address - Country:US
Practice Address - Phone:719-530-2022
Practice Address - Fax:719-539-2065
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44295207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO55325785Medicaid
CO44295OtherSTATE LICENSE
CO55325785Medicaid
CO805261Medicare PIN