Provider Demographics
NPI:1992879241
Name:GELDERMAN-MOFFETT, JANNA K (DO)
Entity type:Individual
Prefix:
First Name:JANNA
Middle Name:K
Last Name:GELDERMAN-MOFFETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-9583
Mailing Address - Country:US
Mailing Address - Phone:303-673-1000
Mailing Address - Fax:
Practice Address - Street 1:100 HEALTH PARK DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9583
Practice Address - Country:US
Practice Address - Phone:303-673-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017103207R00000X
OH34007312207R00000X
CO55567208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2194110Medicaid
WV3810014817Medicaid
CO90800079Medicaid
MI114955900Medicaid
WV3810014817Medicaid
WV4260812Medicare PIN
CO90800079Medicaid