Provider Demographics
NPI:1902889967
Name:LANDSGAARD, HENRY RAY
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:RAY
Last Name:LANDSGAARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:HENRY
Other - Middle Name:R
Other - Last Name:LANDSGAARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 912215
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-2215
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1024 S 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:970-495-7000
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011929207P00000X
CODR.0055268207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3332953Medicaid
MIP00065018OtherRAILROAD MEDICARE PIN
MI3339927Medicaid
CO95937072Medicaid
MI3417756Medicaid
HL011929OtherBLUE CROSS BLUE SHIELD
MIP00065018OtherRAILROAD MEDICARE PIN
F75418Medicare UPIN
CO413485YLA0Medicare PIN