Provider Demographics
NPI:1205888732
Name:CONYERS, JULIE A (MD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:CONYERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16222 W US HIGHWAY 24 STE 210
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-8763
Practice Address - Country:US
Practice Address - Phone:719-364-6487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8325208600000X
CAG89174208600000X
CODR.0030500208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G891740Medicaid
ID806114900Medicaid
F64534Medicare UPIN
ID131312Medicare Oscar/Certification
CA00G891740Medicaid