Basic Information
| Provider Information | |||||||||
| NPI: | 1245299395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRAKE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 185 SUTTLE ST | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813038276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703352232 | ||||||||
| FaxNumber: | 9705659005 | ||||||||
| Practice Location | |||||||||
| Address1: | 52 VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | PAGOSA SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811478368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702642104 | ||||||||
| FaxNumber: | 9702642108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 02908 | IA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 0054066 | CO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1154481273 | 05 | IA | MEDICAID | 1154481273 | 01 | IA | WELLMARK BCBS | OTHER | 2121004 | 05 | IA | MEDICAID |