Provider Demographics
NPI:1104972884
Name:KNUDSON, KELLY P (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:P
Last Name:KNUDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:300 EXEMPLA CIR
Mailing Address - Street 2:SUITE 360
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-3397
Mailing Address - Country:US
Mailing Address - Phone:303-689-6560
Mailing Address - Fax:303-689-6550
Practice Address - Street 1:300 EXEMPLA CIR
Practice Address - Street 2:SUITE 360
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3397
Practice Address - Country:US
Practice Address - Phone:303-689-6560
Practice Address - Fax:303-689-6550
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2010-10-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO46629208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46630597Medicaid
P00727533OtherMEDICARE RAILROAD
COCO300661Medicare PIN