Basic Information
| Provider Information | |||||||||
| NPI: | 1578574588 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELTA FAMILY PHYSICIANS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 MEEKER ST | ||||||||
| Address2: | |||||||||
| City: | DELTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814161920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708745777 | ||||||||
| FaxNumber: | 9708741631 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 MEEKER ST | ||||||||
| Address2: | |||||||||
| City: | DELTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814161920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708745777 | ||||||||
| FaxNumber: | 9708741631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 10/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | MIXTER | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9708745777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 207Q0000X | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CI8541 | 01 | CO | RR MC GRP ID | OTHER | 04009379 | 05 | CO | MEDICAID |