Provider Demographics
NPI:1699740480
Name:VERSACE, ENRICO JOHN (MD)
Entity type:Individual
Prefix:
First Name:ENRICO
Middle Name:JOHN
Last Name:VERSACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 COUNTY ROAD 14
Mailing Address - Street 2:RIO GRANDE HOSPITAL
Mailing Address - City:DEL NORTE
Mailing Address - State:CO
Mailing Address - Zip Code:81132-8719
Mailing Address - Country:US
Mailing Address - Phone:719-657-4102
Mailing Address - Fax:719-657-4106
Practice Address - Street 1:310 COUNTY ROAD 14
Practice Address - Street 2:RIO GRANDE HOSPITAL
Practice Address - City:DEL NORTE
Practice Address - State:CO
Practice Address - Zip Code:81132-8719
Practice Address - Country:US
Practice Address - Phone:719-657-4102
Practice Address - Fax:719-657-4106
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11019208M00000X
CO0053518207R00000X
WA601675062083P0011X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO53518OtherCO LICENSE
CO47105348Medicaid
CO53518OtherCO LICENSE
CO47105348Medicaid
MTG05291Medicare UPIN
WAG05291Medicare UPIN
P00332421Medicare PIN
MTP00332421Medicare PIN