Healthcare Provider Details

I. General information

NPI: 1467072249
Provider Name (Legal Business Name): JOEL SCOTT BONZO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 BELMONT AVE
LA JUNTA CO
81050-2101
US

IV. Provider business mailing address

7495 W 29TH AVE
WHEAT RIDGE CO
80033-8002
US

V. Phone/Fax

Practice location:
  • Phone: 719-383-5500
  • Fax:
Mailing address:
  • Phone: 303-761-1977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTL.0008385
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0067663
License Number StateCO

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: