Provider Demographics
NPI:1902936107
Name:NYSTROM, ROBERT R (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:R
Last Name:NYSTROM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-5114
Mailing Address - Country:US
Mailing Address - Phone:970-350-2471
Mailing Address - Fax:970-350-2418
Practice Address - Street 1:1900 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5114
Practice Address - Country:US
Practice Address - Phone:970-350-2471
Practice Address - Fax:970-350-2418
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30464207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1304641Medicaid
COP00931173OtherMEDICARE RAILROAD CARRIER PTAN
COCO301498Medicare PIN
CO1304641Medicaid
COCOA102091Medicare PIN
CO300082Medicare PIN