=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811989064
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS BRUCE DEYOUNG DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2005
-----------------------------------------------------
Last Update Date | 11/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 313 W DRAKE RD
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80526-2846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-482-8881
-----------------------------------------------------
Fax | 970-482-9646
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4674 SNOW MESA DR STE 140
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80528-8615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-225-5043
-----------------------------------------------------
Fax | 970-482-9646
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 27536
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------