Healthcare Provider Details

I. General information

NPI: 1205997590
Provider Name (Legal Business Name): STACEY L. LUDLOW M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 SPRINGER DR STE 315
HIGHLANDS RANCH CO
80129
US

IV. Provider business mailing address

1631 HOLLY ST
DENVER CO
80220-1442
US

V. Phone/Fax

Practice location:
  • Phone: 720-651-9296
  • Fax:
Mailing address:
  • Phone: 918-808-6905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20434
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR.0059550
License Number StateCO

VII. Legacy identifiers

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

# 1
Identifier200094880A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: