Provider Demographics
NPI:1245452994
Name:DATTILO, PHILIP B III (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:B
Last Name:DATTILO
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2121 E HARMONY RD
Mailing Address - Street 2:STE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-221-1000
Mailing Address - Fax:970-297-6844
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:STE 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3400
Practice Address - Country:US
Practice Address - Phone:970-221-1000
Practice Address - Fax:970-297-6844
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2016-12-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CODR.0047426207RI0011X, 207R00000X
CO47426207RC0000X
NE28429207RI0011X
WY10035A207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO81987064Medicaid
COP01479130OtherRAILROAD
WY1245452994Medicaid
NE$$$$$$$$$00Medicaid
NE$$$$$$$$$00Medicaid
NENA1626027Medicare PIN
CO411243YLB8Medicare PIN
CO81987064Medicaid