Provider Demographics
NPI:1619941739
Name:NOORDEWIER, EDWIN R (MD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:R
Last Name:NOORDEWIER
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 1:1900 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:970-350-2454
Mailing Address - Fax:970-350-2447
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:970-350-2454
Practice Address - Fax:970-350-2447
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29737207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200390030AMedicaid
COP00931165OtherMEDICARE RAILROAD CARRIER PTAN
UTZ3282Medicaid
WY122698300Medicaid
AZ128166Medicaid
CO01297373Medicaid
NE100263923-00Medicaid
NM81581882Medicaid
NM81581882Medicaid
COCOA103677Medicare PIN
NE100263923-00Medicaid