Provider Demographics
NPI:1174518054
Name:BRIGHTWELL, NATHAN L (MD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:L
Last Name:BRIGHTWELL
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 1:1330 CEDAR RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-1406
Mailing Address - Country:US
Mailing Address - Phone:719-963-6677
Mailing Address - Fax:
Practice Address - Street 1:1330 CEDAR RIDGE LN
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-1406
Practice Address - Country:US
Practice Address - Phone:719-963-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2024-01-25
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
CODRP.0000762174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04011995Medicaid
CO13191Medicare ID - Type Unspecified
CO04011995Medicaid