Basic Information
Provider Information | |||||||||
NPI: | 1114187648 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MESA | ||||||||
FirstName: | JODIE | ||||||||
MiddleName: | KAY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HAMER | ||||||||
OtherFirstName: | JODIE | ||||||||
OtherMiddleName: | KAY | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 8540 SCARBOROUGH DR | ||||||||
Address2: | SUITE 100 | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809207502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7199554200 | ||||||||
FaxNumber: | 7193657667 | ||||||||
Practice Location | |||||||||
Address1: | 8540 SCARBOROUGH DR | ||||||||
Address2: | SUITE 100 | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809207502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7199554200 | ||||||||
FaxNumber: | 7193657667 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2008 | ||||||||
LastUpdateDate: | 08/31/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R-9579 | IA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | DR-54111 | CO | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 58052348 | 05 | CO |   | MEDICAID |