Healthcare Provider Details

I. General information

NPI: 1124020417
Provider Name (Legal Business Name): GERALD A. HAMSTRA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4775 JAMESTOWN DR
COLORADO SPRINGS CO
80918-2725
US

IV. Provider business mailing address

P.O. BOX 25819
COLORADO SPRINGS CO
80936-5819
US

V. Phone/Fax

Practice location:
  • Phone: 719-574-7849
  • Fax: 719-574-3776
Mailing address:
  • Phone: 719-574-7849
  • Fax: 719-574-3776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17495
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: