Healthcare Provider Details

I. General information

NPI: 1962465807
Provider Name (Legal Business Name): GLENN MARK SHOPTAUGH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 RAVEN HILLS CT
COLORADO SPRINGS CO
80919-1316
US

IV. Provider business mailing address

82 RAVEN HILLS CT
COLORADO SPRINGS CO
80919-1316
US

V. Phone/Fax

Practice location:
  • Phone: 719-201-4964
  • Fax: 719-447-8987
Mailing address:
  • Phone: 719-201-4964
  • Fax: 719-447-8987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number40437
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: