Healthcare Provider Details

I. General information

NPI: 1134383516
Provider Name (Legal Business Name): BETHANY ENGBLOM DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4856 INNOVATION DR
FORT COLLINS CO
80525-5539
US

IV. Provider business mailing address

4856 INNOVATION DR
FORT COLLINS CO
80525-5539
US

V. Phone/Fax

Practice location:
  • Phone: 970-494-4200
  • Fax: 844-270-1824
Mailing address:
  • Phone: 970-494-4200
  • Fax: 844-270-1824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberDR.0045697
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0045697
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: