Healthcare Provider Details

I. General information

NPI: 1245452994
Provider Name (Legal Business Name): PHILIP B DATTILO III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 09/29/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 E HARMONY RD STE 100
FORT COLLINS CO
80528-3400
US

IV. Provider business mailing address

2121 E HARMONY RD STE 100
FORT COLLINS CO
80528-3400
US

V. Phone/Fax

Practice location:
  • Phone: 970-221-1000
  • Fax: 970-297-6844
Mailing address:
  • Phone: 970-221-1000
  • Fax: 970-297-6844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDR.0047426
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number47426
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberDR.0047426
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number28429
License Number StateNE
# 5
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number10035A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: