Basic Information
Provider Information | |||||||||
NPI: | 1386955516 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TOLBERT | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | REBECCA YACTOR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NIXON | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | REBECCA YACTOR | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 10700 E GEDDES AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ENGLEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 801123800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037619190 | ||||||||
FaxNumber: | 7208744462 | ||||||||
Practice Location | |||||||||
Address1: | 10700 E GEDDES AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ENGLEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 801123800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037619190 | ||||||||
FaxNumber: | 7208744462 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/22/2010 | ||||||||
LastUpdateDate: | 10/13/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 29568 | NE | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD18919 | HI | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | P6300 | TX | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 04-39427 | KS | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | DR.0055337 | CO | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 79454020 | 05 | NM |   | MEDICAID | 71371281 | 05 | CO |   | MEDICAID | 1386955516 | 05 | IA |   | MEDICAID | 191127 | 05 | AZ |   | MEDICAID | 201145320A | 05 | KS |   | MEDICAID |