Provider Demographics
NPI:1881864072
Name:TODD DEXTRADEUR MD PC
Entity Type:Organization
Organization Name:TODD DEXTRADEUR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:C
Authorized Official - Last Name:DEXTRADEUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-289-8184
Mailing Address - Street 1:1324 S. RACE STREET
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-2332
Mailing Address - Country:US
Mailing Address - Phone:720-289-8184
Mailing Address - Fax:303-457-2341
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:720-289-8184
Practice Address - Fax:303-457-2341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
CO35500207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO35500OtherMEDICAL LIC
CO01355007Medicaid
CO35500OtherMEDICAL LIC
COC488408Medicare PIN