Provider Demographics
NPI:1952563702
Name:VANSE, ELISABETH SUSAN (DO)
Entity Type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:SUSAN
Last Name:VANSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ELISABETH
Other - Middle Name:SUSAN
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5147
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:
Practice Address - Street 1:2828 INTERNATIONAL CIR
Practice Address - Street 2:SUITE 140
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3127
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0049778208000000X
MI5101017747208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64474216Medicaid
COCOA109806OtherMEDICARE NUMBER