Healthcare Provider Details

I. General information

NPI: 1679576938
Provider Name (Legal Business Name): DAVID B HOMER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 06/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 WEST COLORADO AVE
TELLURIDE CO
81435
US

IV. Provider business mailing address

PO BOX 2397
TELLURIDE CO
81435-2397
US

V. Phone/Fax

Practice location:
  • Phone: 970-728-6654
  • Fax: 970-728-5412
Mailing address:
  • Phone: 970-728-6654
  • Fax: 970-728-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25645
License Number StateCO

VIII. Authorized Official

Name: DR. DAVID HOMER
Title or Position: OWNER
Credential: MD
Phone: 970-728-6654