Provider Demographics
NPI:1962502567
Name:HIGGINBOTHAM, THOMAS
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:HIGGINBOTHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 S 21ST ST
Mailing Address - Street 2:STE 101
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-4225
Mailing Address - Country:US
Mailing Address - Phone:719-260-8190
Mailing Address - Fax:719-260-6086
Practice Address - Street 1:1430 S 21ST ST
Practice Address - Street 2:STE 101
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-4225
Practice Address - Country:US
Practice Address - Phone:719-260-8190
Practice Address - Fax:719-260-6086
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO275632083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC41671Medicare PIN