Provider Demographics
NPI:1982614897
Name:PHILLIPS, WAYNE F (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:F
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2501 WALNUT STREET
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5753
Mailing Address - Country:US
Mailing Address - Phone:303-440-4599
Mailing Address - Fax:303-440-6133
Practice Address - Street 1:2501 WALNUT STREET
Practice Address - Street 2:SUITE 209
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5753
Practice Address - Country:US
Practice Address - Phone:303-440-4599
Practice Address - Fax:303-440-6133
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO264132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01264134Medicaid
COC72661Medicare PIN
CO01264134Medicaid