1598992521 NPI number — JOHN R DYGERT DO

Table of content: JOHN R DYGERT DO (NPI 1598992521)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598992521 NPI number — JOHN R DYGERT DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DYGERT
Provider First Name:
JOHN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598992521
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
218 E CHEYENNE MOUNTAIN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80906-3720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-465-1579
Provider Business Mailing Address Fax Number:
719-280-6111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218 E CHEYENNE MOUNTAIN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80906-3720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-465-1579
Provider Business Practice Location Address Fax Number:
719-280-6111
Provider Enumeration Date:
06/17/2009

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: 207Q00000X , with the licence number:  0535852 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: DR.0058786 , 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: 0058786 . This is a "COLORADO STATE LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 05-35852 . This is a "KANSAS STATE LICENSE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 200879270A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".