Provider Demographics
NPI:1811989064
Name:DEYOUNG, DOUGLAS BRUCE (DO)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:BRUCE
Last Name:DEYOUNG
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 1:4674 SNOW MESA DR
Mailing Address - Street 2:STE 140
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-8615
Mailing Address - Country:US
Mailing Address - Phone:970-225-5043
Mailing Address - Fax:970-482-9646
Practice Address - Street 1:313 W DRAKE RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-2846
Practice Address - Country:US
Practice Address - Phone:970-482-8881
Practice Address - Fax:970-482-9646
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1275361Medicaid
CODE27536OtherBCBS
CODE27536OtherBCBS
62654Medicare ID - Type Unspecified
E90290Medicare UPIN