Provider Demographics
NPI:1083695316
Name:KAUTZ, BRUCE L (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:KAUTZ
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 1:2685 DUBLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1358
Mailing Address - Country:US
Mailing Address - Phone:719-592-9890
Mailing Address - Fax:719-264-7808
Practice Address - Street 1:2685 DUBLIN BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1358
Practice Address - Country:US
Practice Address - Phone:719-592-9890
Practice Address - Fax:719-264-6808
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30304208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01303049Medicaid