Provider Demographics
NPI:1801845532
Name:DEXTRADEUR, TODD C (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:C
Last Name:DEXTRADEUR
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 1:1324 SOUTH RACE STREET
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210
Mailing Address - Country:US
Mailing Address - Phone:303-777-8333
Mailing Address - Fax:303-777-8338
Practice Address - Street 1:51 W 84TH AVE
Practice Address - Street 2:STE 300
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80260-4883
Practice Address - Country:US
Practice Address - Phone:303-777-8333
Practice Address - Fax:303-777-8338
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0035500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01355007Medicaid
CO35500OtherMEDICAL LICENSE
COC488418Medicare PIN
CO35500OtherMEDICAL LICENSE