Provider Demographics
NPI:1124478458
Name:KELLY, EVAN (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:KELLY
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 1:1960 N OGDEN ST
Mailing Address - Street 2:STE 400
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-3670
Mailing Address - Country:US
Mailing Address - Phone:303-318-1540
Mailing Address - Fax:303-318-2481
Practice Address - Street 1:1375 E 19TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1114
Practice Address - Country:US
Practice Address - Phone:303-812-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTP 00013351390200000X
KY56579208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program