Basic Information
| Provider Information | |||||||||
| NPI: | 1942468129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCINTOSH | ||||||||
| FirstName: | DERIC | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 RIVERSIDE AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702241670 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1625 FOXTRAIL DR STE 190 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706196900 | ||||||||
| FaxNumber: | 9706196990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2008 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 48280 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.