1144464454 NPI number — DR. LIA R MATARRESE MCGIBBON DO

Table of content: DR. LIA R MATARRESE MCGIBBON DO (NPI 1144464454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144464454 NPI number — DR. LIA R MATARRESE MCGIBBON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATARRESE MCGIBBON
Provider First Name:
LIA
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCGIBBON
Provider Other First Name:
LIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1144464454
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1715 IRON HORSE DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGMONT
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80501-9617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-494-4700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 COALTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUPERIOR
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80027-4674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-494-4700
Provider Business Practice Location Address Fax Number:
720-494-4706
Provider Enumeration Date:
04/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  279671 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: 50866 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 70976287 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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