Healthcare Provider Details

I. General information

NPI: 1174587265
Provider Name (Legal Business Name): BRUCE BLYTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E 19TH AVE SUITE 3750
DENVER CO
80218-1216
US

IV. Provider business mailing address

1601 E 19TH AVE SUITE 3750
DENVER CO
80218-1216
US

V. Phone/Fax

Practice location:
  • Phone: 303-839-7200
  • Fax: 303-839-7229
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number31504
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: