Healthcare Provider Details

I. General information

NPI: 1902025935
Provider Name (Legal Business Name): EDWIN L BACA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 INTEGRITY CENTER PT
COLORADO SPRINGS CO
80917-1683
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-9071
US

V. Phone/Fax

Practice location:
  • Phone: 719-591-2558
  • Fax: 719-591-2596
Mailing address:
  • Phone: 970-624-4036
  • Fax: 970-490-4378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number45333
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0045333
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: