Provider Demographics
NPI:1568455061
Name:TRAVERS, GERALD RICHARD (DPM)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:RICHARD
Last Name:TRAVERS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 E PIKES PEAK AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5619
Mailing Address - Country:US
Mailing Address - Phone:719-475-8080
Mailing Address - Fax:719-475-0913
Practice Address - Street 1:1612 E PIKES PEAK AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5619
Practice Address - Country:US
Practice Address - Phone:719-475-8080
Practice Address - Fax:719-475-0913
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO283213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04011300Medicaid
COAT5146192OtherDEA LICENSE#
COCA0503Medicare PIN
COCA0513Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
CO04011300Medicaid
COAT5146192OtherDEA LICENSE#