Healthcare Provider Details

I. General information

NPI: 1548840622
Provider Name (Legal Business Name): ETHAN PADDOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MERCADO ST STE 205
DURANGO CO
81301-7310
US

IV. Provider business mailing address

1 MERCADO ST STE 205
DURANGO CO
81301-7310
US

V. Phone/Fax

Practice location:
  • Phone: 970-385-7272
  • Fax:
Mailing address:
  • Phone: 970-385-7272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberDR.0077227
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: