Basic Information
| Provider Information | |||||||||
| NPI: | 1538154257 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN DER WERF | ||||||||
| FirstName: | GUY | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | ESTES PARK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805176312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705862200 | ||||||||
| FaxNumber: | 9705774536 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 STANLEY AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | ESTES PARK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805176356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705862344 | ||||||||
| FaxNumber: | 9705869060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 09/27/2018 | ||||||||
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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 | 207Q00000X | 31317 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1313170 | 05 | CO | MEDICAID | 01313170 | 05 | CO | MEDICAID |