Provider Demographics
NPI:1265624811
Name:CORSON, THOMAS JACOB
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JACOB
Last Name:CORSON
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:THOMAS
Other - Middle Name:JACOB
Other - Last Name:CORSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 173817
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3817
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:2000 BOISE AVE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-5006
Practice Address - Country:US
Practice Address - Phone:970-635-4071
Practice Address - Fax:970-635-4177
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT047701207P00000X, 208D00000X
CO48063207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO021193OtherKAISER COMMERCIAL NUMBER
CO86452550Medicaid
COCOA104347Medicare PIN