Provider Demographics
NPI:1902025935
Name:BACA, EDWIN L (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:L
Last Name:BACA
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Gender:M
Credentials:MD
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Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4036
Mailing Address - Fax:970-490-4378
Practice Address - Street 1:4323 INTEGRITY CENTER PT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-1683
Practice Address - Country:US
Practice Address - Phone:719-591-2558
Practice Address - Fax:719-591-2596
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2016-07-28
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Provider Licenses
StateLicense IDTaxonomies
CO453332083X0100X
CODR.0045333207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO70036586Medicaid