Basic Information
| Provider Information | |||||||||
| NPI: | 1538149794 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEGAL | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706242403 | ||||||||
| FaxNumber: | 9704904173 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 E BOULDER ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193651292 | ||||||||
| FaxNumber: | 7193656997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2006 | ||||||||
| LastUpdateDate: | 07/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OP00002054 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DR.0052634 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DO23435 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 244091 | 05 | OR | MEDICAID | 138926 | 01 | OR | MEDICARE PTAN | OTHER |