Basic Information
| Provider Information | |||||||||
| NPI: | 1972595783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FODOR | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8890 N UNION BLVD | ||||||||
| Address2: | STE 160 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809207799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193659950 | ||||||||
| FaxNumber: | 7193659969 | ||||||||
| Practice Location | |||||||||
| Address1: | 1725 E BOULDER ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809095768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193656300 | ||||||||
| FaxNumber: | 7193656094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 01/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 32725 | CO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 14287820 | 05 | CO | MEDICAID |