Provider Demographics
NPI:1326359076
Name:WEIDEMANN, GORDON DAVID (MSPT)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:DAVID
Last Name:WEIDEMANN
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 3053
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81602
Mailing Address - Country:US
Mailing Address - Phone:970-379-5197
Mailing Address - Fax:970-947-9048
Practice Address - Street 1:818 COLORADO AVE, SUITE 300
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601
Practice Address - Country:US
Practice Address - Phone:970-379-5197
Practice Address - Fax:970-945-0409
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5081225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO5081OtherSTATE LICENSE NUMBER