Provider Demographics
NPI:1811972219
Name:WEBER, BRUCE J (DO)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:J
Last Name:WEBER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9141 GRANT ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-4374
Mailing Address - Country:US
Mailing Address - Phone:303-252-0100
Mailing Address - Fax:303-252-0127
Practice Address - Street 1:9141 GRANT ST STE 140
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4367
Practice Address - Country:US
Practice Address - Phone:303-252-0100
Practice Address - Fax:303-252-0127
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23073207QA0505X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01230739Medicaid
COC10962Medicare PIN
COD28314Medicare UPIN
CO01230739Medicaid