Provider Demographics
NPI:1285877183
Name:A GLENN SHOPTAUGH MD PC
Entity type:Organization
Organization Name:A GLENN SHOPTAUGH MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:SHOPTAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-577-4200
Mailing Address - Street 1:1715 N WEBER ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-7532
Mailing Address - Country:US
Mailing Address - Phone:719-577-4200
Mailing Address - Fax:719-442-6595
Practice Address - Street 1:1715 N WEBER ST
Practice Address - Street 2:SUITE 120
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-7532
Practice Address - Country:US
Practice Address - Phone:719-577-4200
Practice Address - Fax:719-442-6595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14141208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01141415Medicaid