Healthcare Provider Details

I. General information

NPI: 1558363234
Provider Name (Legal Business Name): JACK FORD M D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 AUSTIN BLUFFS PKWY STE 306
COLORADO SPRINGS CO
80918-5755
US

IV. Provider business mailing address

3505 AUSTIN BLUFFS PKWY STE 306
COLORADO SPRINGS CO
80918-5755
US

V. Phone/Fax

Practice location:
  • Phone: 719-475-1810
  • Fax: 719-475-1812
Mailing address:
  • Phone: 719-475-1810
  • Fax: 719-475-1812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberDR0016135
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: