Provider Demographics
NPI:1053523753
Name:MICHAEL, ROBERT TODD (DO)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:TODD
Last Name:MICHAEL
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 1:6125 HABITAT DR APT 1082
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3227
Mailing Address - Country:US
Mailing Address - Phone:303-818-8859
Mailing Address - Fax:719-438-2254
Practice Address - Street 1:1211 LUTHER STREET
Practice Address - Street 2:
Practice Address - City:EADS
Practice Address - State:CO
Practice Address - Zip Code:80136
Practice Address - Country:US
Practice Address - Phone:719-438-2251
Practice Address - Fax:719-438-2254
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64022056Medicaid
COC76640Medicare UPIN
CO1480302Medicare ID - Type Unspecified