Provider Demographics
NPI:1942382023
Name:FT LUPTON MEDICAL TEAM PC
Entity Type:Organization
Organization Name:FT LUPTON MEDICAL TEAM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SELWYN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:SPRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-857-1007
Mailing Address - Street 1:308 DENVER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1822
Mailing Address - Country:US
Mailing Address - Phone:303-857-1007
Mailing Address - Fax:303-857-1227
Practice Address - Street 1:308 DENVER AVE
Practice Address - Street 2:
Practice Address - City:FORT LUPTON
Practice Address - State:CO
Practice Address - Zip Code:80621
Practice Address - Country:US
Practice Address - Phone:303-857-1007
Practice Address - Fax:303-857-1227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17794207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4009915OtherAETNA
CO04018990Medicaid
CO04018990Medicaid
D23344Medicare UPIN