Basic Information
| Provider Information | |||||||||
| NPI: | 1669442224 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | MARTI | ||||||||
| MiddleName: | RUE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 S ROLLIE AVE | ||||||||
| Address2: | BILLING DEPT - CREDENTIALIST | ||||||||
| City: | FORT LUPTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806211508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032864560 | ||||||||
| FaxNumber: | 3032864589 | ||||||||
| Practice Location | |||||||||
| Address1: | 1860 E EGBERT ST | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806012475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036594000 | ||||||||
| FaxNumber: | 3036554924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0427008 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 0427008 | KS | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | DR.0056041 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2086802102 | 05 | KS | MEDICAID | 100345670G | 05 | KS | MEDICAID |