Healthcare Provider Details

I. General information

NPI: 1952563702
Provider Name (Legal Business Name): ELISABETH SUSAN VANSE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELISABETH SUSAN MARTIN DO

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 INTERNATIONAL CIR SUITE 140
COLORADO SPRINGS CO
80910-3127
US

IV. Provider business mailing address

3205 N ACADEMY BLVD SUITE 130
COLORADO SPRINGS CO
80917-5147
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-5700
  • Fax:
Mailing address:
  • Phone: 719-632-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR.0049778
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101017747
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: