Provider Demographics
NPI:1023016128
Name:WELLER, KENNETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:WELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:8925 RIDGELINE BLVD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-2500
Mailing Address - Country:US
Mailing Address - Phone:303-471-6500
Mailing Address - Fax:303-471-5908
Practice Address - Street 1:8925 RIDGELINE BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-2500
Practice Address - Country:US
Practice Address - Phone:303-471-6500
Practice Address - Fax:303-471-5908
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO36799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF23701Medicare UPIN
806206Medicare PIN