Provider Demographics
NPI:1700882123
Name:OLDEMEYER, JOHN BRADLEY (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRADLEY
Last Name:OLDEMEYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J. BRADLEY
Other - Middle Name:
Other - Last Name:OLDEMEYER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2121 E HARMONY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-221-1000
Mailing Address - Fax:970-297-6860
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:UNIT 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3401
Practice Address - Country:US
Practice Address - Phone:970-221-1000
Practice Address - Fax:970-297-6860
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42588207RC0000X, 207RI0011X, 207UN0901X
NE20564207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119686300Medicaid
WV3810024590Medicaid
CO16155564Medicaid
COP00970363OtherRR MEDICARE
G75250Medicare UPIN
COCOA102398Medicare PIN
COP00970363OtherRR MEDICARE
CO16155564Medicaid
WV3810024590Medicaid