Provider Demographics
NPI:1902903933
Name:RACHJAIBUN, DERIC J (MD)
Entity Type:Individual
Prefix:DR
First Name:DERIC
Middle Name:J
Last Name:RACHJAIBUN
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 1:11990 GRANT ST STE 110
Mailing Address - Street 2:
Mailing Address - City:NORTHGLENN
Mailing Address - State:CO
Mailing Address - Zip Code:80233-1122
Mailing Address - Country:US
Mailing Address - Phone:720-928-0244
Mailing Address - Fax:720-928-0247
Practice Address - Street 1:11990 GRANT ST STE 110
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80233-1122
Practice Address - Country:US
Practice Address - Phone:720-928-0244
Practice Address - Fax:720-928-0247
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41861207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57474524Medicaid
CO31930743Medicaid
COI41286Medicare UPIN
CO31930743Medicaid
CO57474524Medicaid
COCO303382Medicare PIN