Provider Demographics
NPI:1174555973
Name:REPERT, WILLIAM B
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:B
Last Name:REPERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT 2215
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-0001
Mailing Address - Country:US
Mailing Address - Phone:800-553-4924
Mailing Address - Fax:
Practice Address - Street 1:1024 LEMAY AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3929
Practice Address - Country:US
Practice Address - Phone:800-553-4924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21060174400000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104344700Medicaid
CO930025633OtherRAILROAD MEDICARE
CO01210608Medicaid
COE35412Medicare UPIN
COCS5038Medicare PIN