Healthcare Provider Details

I. General information

NPI: 1346551637
Provider Name (Legal Business Name): LAUREN WITTE MILTENBERG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 02/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E ELIZABETH ST FORT COLLINS YOUTH CLINIC
FORT COLLINS CO
80524-4007
US

IV. Provider business mailing address

1200 E ELIZABETH ST FORT COLLINS YOUTH CLINIC
FORT COLLINS CO
80524-4007
US

V. Phone/Fax

Practice location:
  • Phone: 970-267-9510
  • Fax: 970-482-6938
Mailing address:
  • Phone: 970-267-9510
  • Fax: 970-482-6938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0052611
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number2010017743
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: